Survivorship Update January 2015 The Royal Wolverhampton NHS Trust James Owen Senior Cancer Services Manager

Background

 Patient Held Care Planning Document  Urology transfer of follow up to community CQUINs

 Patient seen  Discuss Treatment options and / or diagnosis  Copy of document goes to patient  Document scanned and saved on shared drive  Somerset Cancer Register updated  Put onto patients electronic record and sent electronically to GP Patient Held Care Planning Document

Cancer Long Term Follow Up  Radically treated prostate cancer patients who are group are those who are:  18 months or more on from completion of radiotherapy, surgery or other radical treatments. On-going hormonal therapy is not a contraindication.  With a stable PSA (as judged by the clinician) and no other symptoms of metastatic disease  Stable toxicity of treatment with any appropriate investigations completed (e.g. proctoscopy for rectal bleeding)  Patients receiving palliative therapy  Biochemically and clinically stable (as judged by the clinician)  Maintained on current therapy for 6 or more months  No uncontrolled symptoms of malignancy  Patient given information on MSCC.  Patients with Prostate Cancer on Active Surveillance  Patients initially assessed by the urologists and felt to be suitable for community follow up.  PSA criteria for re-referral defined and documented on transfer of care document (see appendix C) Month SeenDischarge to GPOtherGrand Total May2 2 Jun10 Jul18119 Aug18 Sep34135 Oct32 Nov16 Dec12 Grand Total

Paper based HNA

eHNA Reviewed use of paper HNA Visited Coventry to see it in action Submitted bid 14/4/14 Bid Accepted June 2014 Met with I.T, Macmillan and Governance July 14 Final Agreement on kit and Governance August 14 Ordered equipment and Mapped out pathways and surveyed signal strength September 14 Ipads arrived October 2014, configured Ipads and double checked all areas for signal strength Correct Infection Prevention Ipad Cases arrived November 14 Pilot Started December 14

How does eHNA work? Patient undertakes eHNA on Ipad Individual Careplan document template created on web Nurse runs through Careplan document with patient Careplan put on portal and SCR updated

National Evaluation

 SCR vs Letters  Talked to Oncologists and Macmillan GP Representative  Audit Letters in Oncology  Design Template (with Macmillan GP Representative) for reference when dictating letters End of Treatment Summary

Patient Details Letter Date Diagnosis Diagnosis Date Stage of disease Treatment undertaken GP actions required Ongoing management Required Symptoms for referral back to the service Risk/late effects of Treatment Does the patient have a Prescription charge exemption? Is the patient on the Palliative Care or Supportive Register? Has the patient had a DS1500 form completed? Details of referrals made to other services Summary of patient information given (i.e. leaflets etc) Additional information relating to lifestyle Trust Contact for queries regarding the patient End of Treatment Summary

 Colorectal Pilot  End of Treatment supply HNA and Personalised management Plan  Prescribe relevant workshop  Tailored, Nurse led, follow up coupled with workshop attendance Health and Wellbeing Event / Follow Up

 Review how this could work with other MDT teams

 Operational Policy and Annual Report Update  MQUISS Standards  Volunteer Training Events  Possible Refurbishment (MQUEM) Macmillan Information centre

 Release Strategy Document (and keep to it)  New Macmillan Funded Post Going Forward

Thank you for Listening James Owen Senior Cancer Services Manager