Cancer is a long-term condition, requiring care and support, but with ever-expanding demands on general practice, there are frustrations around how to incorporate this in an already stretched system. This article will explore how this can be managed by using group consultations and the successes that can be gained from a plethora of perspectives—from individuals and families to professionals, communities and populations.
Our challenge
Statistics from Macmillan (2016) show that with advances in treatment, more people are living with and beyond cancer. Following cancer treatment, individuals may have ongoing needs and concerns, including physical, mental, lifestyle and information needs. Those living with and beyond cancer may not have been systematically followed up in primary care in the current system. As part of the mandated Quality and Outcomes Framework (QOF) (NHS Digital, 2019) in general practice, cancer care reviews are financially rewarded for one single review within 6 months after a cancer diagnosis. After this one-off review, no further review is needed to comply with the QOF framework (NHS Digital, 2019). This means those living with and beyond cancer in the community may only receive follow up around concerns by booking self-initiated appointments with their GP, advanced clinical practitioner or practice nurse. Some individuals, but not all, may still have access to cancer nurse specialists for self-initiated follow-up over any concerns they have.
There is evidence that a holistic needs assessment (HNA), performed at regular intervals, dependent on the individual's needs, improves outcomes for people living with cancer (Macmillan, 2016). A HNA is a process that elicits needs and helps to educate individuals to ensure they make informed choices about their health and wellbeing. Subsequently, it hopes to motivate the population to make healthy lifestyle choices that will lead to a reduction in the recurrence of cancer and the development of other long-term conditions. This would improve the overall population health, which has individual and societal gains from a lifestyle and economic perspective.
At Lancaster Medical Practice, a large general practice in Lancashire, we are trying to address the needs of the community through developing the role of the general practice nurse to undertake cancer care reviews. This complements the role well, as general practice nurses are experts in chronic disease management (Macmillan, 2016), an umbrella term that encompasses holistic care of long-term conditions. We have successfully embedded cancer care reviews in our routine annual chronic disease management system. Consequently, we have taken this one step further, by using group consultations for cancer care reviews. This is an innovative approach that started following an opportunity for group consultation training.
Our group consultation design
A search of our database for patients living with cancer generated a list that the team checked to ensure patients were suitable for a group consultation. The practice nurse (clinical lead) rang patients and invited them. The team sent out information packs and rang with a telephone reminder before the group consultation to ensure attendance.
The group consultation was focused on their cancer review. Using the Macmillan Holistic Needs Assessment (HNA) (Macmillan, 2020) as a framework for the group consultation, the team elicited and responded to patients' concerns. The HNA also quantified the impact of group consultation on patient's concerns. Six patients were followed up in two group consultations over 6 months.
Efficiency of group consultation
The group consultation saved 30 minutes of clinician time compared to six 1:1 reviews. Usually the GP does the cancer review, but this utilised the expertise of the practice nurse, was time efficient and ensured patients' needs were addressed.
There was minimal preparation for the group consultation as few biometrics are tracked in cancer reviews, again ensuring valuable time in general practice was used wisely.
Impact on wellbeing
The impact on wellbeing was observed through the data collected using the concerns checklist. At baseline, 66% of patients had at least one area of concern (Table 1). On average, those patients reported 8.3 specific concerns (4 physical concerns; 2.5 emotional concerns and 1.8 lifestyle and information concerns). At follow up, 66% no longer had concerns (Table 2). The 33% who did, had an average of 4 physical, 1 lifestyle, 1 information and 2 emotional concerns. The total number of concerns at baseline was 33. At follow up, it reduced to 14; a reduction of 58%. The average self-assessed ‘overall level of concern’ was 3 at baseline and 2.2 at follow up; a reduction of 36%.
Table 1. Baseline holistic needs assessment
| Patient number | Number of physical concerns | Number of emotional concerns | Number of lifestyle or information needs | Overall level of concern (1 being lowest and 10 being highest) |
|---|---|---|---|---|
| 1 | 11 | 6 | 1 | 5 |
| 2 | 1 | 4 | 1 | 4 |
| 3 | 1 | 0 | 4 | 1 |
| 4 | 3 | 0 | 1 | 6 |
| 5 | 0 | 0 | 0 | 1 |
| 6 | 0 | 0 | 0 | 1 |
Table 2. Holistic needs assessment following group consultation cancer care review
| Patient number | Number of physical concerns | Number of emotional concerns | Number of lifestyle or information needs | Overall level of concern (1 being lowest and 10 being highest) |
|---|---|---|---|---|
| 1 | 8 | 5 | 0 | 4 |
| 2 | 0 | 2 | 0 | 2 |
| 3 | 0 | 0 | 2 | 1 |
| 4 | 1 | 0 | 0 | 4 |
| 5 | 0 | 0 | 0 | 1 |
| 6 | 0 | 0 | 0 | 1 |
Experience of care
We also asked the patients what their thoughts and feelings were regarding the experience of their group consultation. Patients felt the group consultation worked well for ongoing follow up and assessment. They also thought it could have worked for their initial primary care review following diagnosis, which is the component mandated in the QOF Framework that was historically carried out by GPs. Patients were happy to talk in the group and felt that they learnt from each other.
Clinician experience
From the clinician's perspective, group consultations provide an invigorating experience, that avoids repetition. The clinician feels able to provide a holistic, person-centred experience for patients, leading to a motivating, rewarding feeling with a great level of job satisfaction. Specifically relating to cancer care, the experience has shown patients want to talk to professionals about their experiences and concerns, but there has been a lack of support to facilitate this in practice, so to be able to fill this gap for a rounded approach with holism is exciting.
Going forward
The success of this trial prompted conversations between the author and a local uro-oncologist, who was also interested in group consultations. This led to the development of an integrated prostate cancer pilot event, encompassing health and wellbeing information, joint group consultations run by a cancer nurse specialist (CNS) and the general practice nurse, and consultant follow up. The author worked with the consultant and CNS to organise the session. In total, 9 patients attended, as well as colleagues from the voluntary sector. The patients were at a similar point in their journey, all being due a 6-week post-radiotherapy or a 3-month post-surgery review. In addition to peer review, clinicians shared health and wellbeing information including healthy eating and exercise. The initial trial of this project received excellent feedback from patients, relatives and the professionals invited. The energy and motivation in the room at the trial event felt tangible, with everyone leaving satisfied and well informed.
The use of group consultations within all areas of chronic disease management and long-term conditions is now being explored by the practice. The practice has the aim of having regular group consultations, on at least a weekly basis, if not more often, for all chronic diseases, particularly diabetes, asthma, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD) and cancer. This will involve the entire multi-professional clinical team, who are receiving support and training to do so. This undoubtedly is encountering some challenges, as a new way of working for patients, professionals and the practice as a whole, but all feedback to date has been positive and the idea well-received. Therefore, with further work we will have a systematic approach for group consultations embedded in daily practice. With the support of the multi-disciplinary team involved, the integrated prostate cancer event requires further trials and input. However, this could potentially eradicate unwarranted variation for prostate cancer treatment and information provision locally, so is an avenue worth pursuing.
Conclusion
On a small scale, we have proven a new avenue for exploration in cancer care reviews in general practice. This highlights the importance of embedding cancer care reviews in the general practice nurse role to ensure our communities and populations are supported. Present knowledge shows group consultations, as well as traditional one-to-one chronic disease reviews, provide much needed support for our patients. However, further work is ongoing to provide more research and statistics.
KEY POINTS
- Individuals, communities and populations need effective cancer care reviews, in a timely manner, on a regular basis
- A systematic approach for practice nurses to care for patients living with and beyond cancer, as they would with other long-term chronic diseases, works well
- Group consultations provide effective care for chronic disease management, and specifically for cancer care
Further reading
- ELC Programme — https://elcworks.co.uk/elc-group-consultations/
- Macmillan — https://www.macmillan.org.uk/
- Schofield P, Gough K, Lotfi-Jam K et al. Nurse-led group consultation intervention reduces depressive symptoms in men with localised prostate cancer: a cluster randomised controlled trial. BMC Cancer. 2016;16:637. 10.1186/s12885-016-2687-1