The NHS is undergoing another period of intense change. Nowhere is this more apparent than in the delivery of cancer care. The Government has set out targets and aspirations in the NHS Plan and the NHS Cancer Plan. These aims can be simply summarised: to make care more efficient and patient centred.
This implies making sure that patients get the treatment they want, how and when they want it. This may need to be accomplished without any significant increase in staffing or funding. Efficiency must improve, and the care pathway is a useful tool for improvement.
The Salisbury Unit
In Salisbury, we have been active in developing care pathways, and in 1996 the trust was asked by the South West Region to develop a breast care pathway. This led, in 1998, to our unit being awarded Beacon status. It was one of the original eight Cancer Beacons and one of two dealing with breast cancer.
From 1999 onwards, we have been involved in phase one of the National Cancer Collaborative. This has been a very exciting project, which is unique in the world in trying to change the process of cancer delivery throughout an entire health service.1
When the first phase of the Collaborative ended in April 2001, I was appointed as one of the two national clinical leads for breast cancer. Our role is to make the important work of the Collaborative more widely known.
As a further reflection of the success of the Salisbury Unit, we were awarded the National Health and Social Services award for the improvement of the lives of patients with cancer in Autumn 2001.
What is an integrated care pathway?
An integrated care pathway is a map of the process for management of a common clinical condition or situation.2,3 It should inform the users about what to do, when to do it, who is the most appropriate member of staff to perform a task and where it should be performed. It should challenge convention and thereby improve the care given.
Mapping the patient journey
The first step in forming a care pathway is to identify the members of the multidisciplinary team. This includes all the providers of care – nurses, medical and allied staff – involved in the treatment of the particular patient group.
It is often a surprise to discover how many different individuals are involved in the treatment of a patient group. If these people do not work in a coordinated way, it is not surprising if the results of treatment are variable. It is also important to remember that patients are part of the team, and an effort must be made to incorporate them.
Once the team members have been identified they need to discuss the existing patient 'journey' and map it out. This may involve following patients through the process from GP referral, to the clinic, inpatient treatment, discharge from hospital and then aftercare. Storyboards may help in visualising this journey.
The range of delays at all stages in the pathway should be recorded to identify areas where change is likely to have most effect. The views of patients on where they feel least well supported and informed, and most vulnerable should be used to 'colour' the simple story.
In a complicated disease process it may be most efficient to divide the team into subgroups to seek solutions for the parts of the pathway most within their field of expertise.
Local GP representatives led the subgroup that looked at the referral process, and they continue to be involved in developing the GP role.
The breast care pathway
In this section I will describe how our breast care pathway has evolved and functions.4
Until recently, all hospital referrals were made using free text letters sent by post. Although a GP letter contains useful data to assess referral priority,5 the requirements for rapid referral and assessment of patients with suspected cancer have necessitated a rethink.
The referral should be simple and allow patient choice. A referral template, which incorporates referral guidance, has many advantages. Referral guidelines, although available, do not need to be used to refer most patients. In our breast clinic, we initially used a simple tick-box system based on 1995 referral guidelines (see Figure 1, below).6
|Figure 1: A simplified version of our initial referral template*|
|Breast lump||Severe breast pain|
|Asymmetrical lumpiness||Unilateral pain in patient >50 years|
|Other (please elaborate below)||Nipple retraction|
|Eczema / Rash|
* If any urgent features are indicated the patient is seen urgently
Although simple to use, a system of this type can result in an increase in the percentage of urgent referrals. A more complex scoring system, which incorporates current referral guidance7 allows referrals to be more accurately prioritised and also gives information on the relative discriminating value of different features in predicting cancer (see Figure 2, below).
|Figure 2: Modified referral template*|
|Symptoms and signs||Circle if present|
|Discrete lump R/L||5|
|Definite signs of malignancy (ulcer, skin nodules, skin distortion) R/L||10|
|Asymmetrical nodularity R/L||3|
|Age over 40 years||5|
|Past history of breast cancer + new symptom or sign||10|
|Persistent unilateral mastalgia in a postmenopausal woman R/L||1|
|Nipple discharge – if age over 50 years or blood-stained or single duct R/L||1|
|Nipple retraction, distortion or eczema R/L||1|
|Family history of breast cancer (relative diagnosed <40 years or 2+ relatives of any age)||2|
* Patients with a score of 10 or over are seen urgently
Since the introduction of the modified template the percentage of urgent referrals has fallen from 80% to 34% without a reduction in the percentage of patients with breast cancer seen urgently.
The template is faxed to a central point in the hospital, the breast care office. As the priority of referral is explicit, the form does not need to be seen by a clinician, and an appointment can be arranged by a member of the administrative team instead. The appointment can be faxed directly back to the GP surgery and then passed onto the patient before being confirmed by post.
Although this system is sound in principle, a major risk is that because of pressure of work the appointment may not be sent back to the surgery while the patient is still there and it may not be convenient for her.
An improved scheme has therefore been introduced by which the GP gives the patient an information leaflet and video about the clinic, and contact details for our office. Having assimilated the information the patient can then telephone our office to make the appointment directly.
We have not been keen to facilitate direct GP booking of the appointment because the security of patient data when electronically transferred cannot be guaranteed and there are fears that this system would increase GPs' workload.
All referrals are received in the office within minutes and an appointment made to suit the patient. We are currently able to see all patients within 2 weeks.
Most patients whose referral is non-urgent will not have significant pathology.
The assessment process involves examination to exclude the presence of a discrete mass, and breast imaging by X-ray or ultrasound.
We hypothesised that many of these patients could be adequately reassured by their GP.8 We have therefore piloted a scheme where a small number of local GPs have attended our symptomatic clinic on between four and six occasions. We then discussed which of the patients they had seen in clinic could have been managed in primary care.
A scheme was devised by which these GPs could evaluate their patients without necessarily referring them to the clinic (see Figure 3, below).
|Figure 3: Flowchart for direct GP assessment|
The GPs fax the patient's clinical details to the breast office, using the same form used for evaluation in the clinic. The GP indicates the investigations he or she feels are required, which we then organise. The results are returned to our office, and a copy sent to the GP. A letter is sent from the breast care office to the patient with the result.
Patients are informed that if at any time they feel that their symptoms have changed and they would like to be seen in the hospital clinic they can telephone the hospital directly.
The pilot scheme has so far trained three GPs, and over 12 months they have assessed 32 patients. Assuming their normal workload, this is about 50% of the patients with breast symptoms who they would normally have referred over this interval.
The investigations were reassuring in all but one patient who was found to have a small tumour in the asymptomatic breast. No other patients have so far requested or needed hospital assessment.
The interval from patients seeing their GP to completing investigation has on average been 14 days, which is comparable with that required to evaluate urgent referrals, but has avoided a hospital assessment in addition to that by the GP. The length of GP consultation is similar to that needed to make a standard referral.
The breast office does most of the paperwork and so the GP's workload should not increase. We are trying to promote the notion and reality of a partnership between the hospital clinic and primary care in the management of patients with breast symptoms.
The pilot has been evaluated and another small group of GPs is to be trained. Given the current climate of clinical governance on the one hand, and the increasingly complex and individualised hospital pathways on the other, a degree of GP specialisation is probably inevitable. We therefore anticipate that this and similar schemes will be of value.
Discharge from hospital
The process of planning for discharge starts before admission, in the nurse-led pre-assessment clinic. This may involve social adjustments and education, for example in wound and drain care to allow an early discharge.
When a patient is discharged, a summary is faxed to the GP and to an identified nurse in each practice, who is responsible for initiating home visits. If there are any problems at home the patient and the nurse have contact details to obtain advice from the hospital.
The drain is removed in the follow-up clinic 9 days after the operation. This has led to a reduction in mean hospital stay from 8 to 3 days without any increase in complications.9
Involvement in a pathway can be a rewarding and exciting experience. The reward is that our patients receive better treatment, while members of the team work more efficiently because there is less duplication of tasks, and those tasks are better suited to the individual's training and interests. We have improved the referral process, making it simpler but more accurate in selecting those patients at risk of having breast cancer. Box 1 (below) lists the benefits of the Salisbury pathway.
We hope that by involving more GPs in evaluating their patients we can continue to see urgent referrals rapidly, while enabling more GPs to reassure those patients who do not have serious pathology.
|Box 1: Benefits of the Salisbury pathway|
- Kerr D, Bevan H, Gowland B et al. Redesigning Cancer Care. Br Med J 2002; 324: 164-6.
- Edwards JNT. Clinical care pathways: a model for the effective delivery of health care. J Integrated Care 1998; 2: 59-62.
- Ibarra V, Titler MG, Reiter RC. Issues in the development and implementation of clinical pathways. AACN Clinical Issues 1996; 7: 436-47.
- Sales DNT. Quality assurance: a pathway to excellence. Houndmill, Hants: MacMillan Press, 2000.
- Marsh SK, Archer TJ. Accuracy of general practitioner referrals to a breast clinic. Ann R Coll Surg Engl 1996; 78: 203-5.
- Austoker J, Mansel R, Baum M, Hobbs R. Guidelines for referral of patients with breast problems. Sheffield: NHS Breast Screening Programme on behalf of the Department of Health Advisory Committee on Screening, 1995.
- Austoker J, Mansel R. Guidelines for referral of patients with breast problems, 2nd edn. Sheffield: NHS Breast Screening Programme on behalf of the Department of Health Advisory Committee on Screening, 1999.
- Cochrane RA, Singhal H, Moneypenny IJ et al. Evaluation of general practitioners referrals to a specialist breast clinic according to the UK national guidelines. Eur J Surg Oncol 1997; 23: 198-201.
- Horgan K, Benson EA, Miller A, Robertson A. Early discharge with drain in situ following axillary lymphadenectomy for breast cancer. Breast 2000; 9: 90-2.
NHS Beacon Awards
Beacon status is awarded to practices, trusts and other healthcare organisations within the NHS that have demonstrated good practice. The NHS Beacon programme aims to spread best practice across the health service. For further information visit the website: www.nhs.uk/beacons