Recent years have seen improved outcomes for people diagnosed with cancer, with average life expectancy increasing beyond 10 years on average (Maher et al, 2018). The numbers of people living with cancer continues to grow, with a lifetime risk of cancer of 1 in 2 (Ahmad et al, 2015). With increasing numbers of those living with and beyond cancer (Maddams et al, 2012), there is a greater need for models of care that best meet the needs of those who are surviving, with the role of primary care becoming increasingly important. For many, cancer has transitioned to a long-term condition (LTC).
With 70% of people with cancer having another LTC, as displayed in Figure 1 (Macmillan, 2015), this adds to the complexity of care provision. The National Institute for Health and Care Excellence (NICE) (2016) outlines best practice for people living with multi-morbidities and emphasises the value of an integrated and holistic approach to care. Initiatives to move follow-up care out of hospital (eg for prostate cancer) enable an integrated approach to care to be possible. In addition, there is growing recognition of the essential role primary care teams have in supporting those living with and beyond cancer, as they have regular ongoing contact with those patients through LTC management (Blane and Lewandowska, 2019).
Figure 1. People with cancer and other long-term conditions in the UK. Macmillan, 2015
The NHS Long Term Plan (2019) sets out a number of interventions that promote personalised cancer care and these are laid out in Table 1.
Table 1. Personalised cancer care and support interventions
| Personalised care and support planning (based on holistic needs assessments) ensures people's physical, practical, emotional and social needs are identified and addressed at the earliest opportunity |
| End of treatment summaries provide both the person and their GP with valuable information, including a detailed summary of treatment completed, potential side effects, signs and symptoms of recurrence and contact details to address any concerns |
| Primary care cancer care review is a discussion between the person and their GP/primary care nurse about their cancer journey. This helps the person to discuss any concerns, and, if appropriate, to be referred to services or signposted to information and support that is available in their community and from charities |
| Health and wellbeing information and support includes the provision of accessible information about emotional support, coping with side effects, financial advice, getting back to work and making healthy lifestyle choices. This support will be available before, during and after cancer treatment |
Patient experience
An annual survey of cancer patients in England provides data on patients' experience in hospital and their out of hospital care (Picker, 2019). The out of hospital questions include support for patients during treatment from their GP and practice nurse. Data from 2019 demonstrate that nationally only 39.1% definitely felt well supported by their GP or practice nurse during their cancer treatment. Analysis of London data in previous years show that patients from lower socioeconomic groups and patients who are not white report a poorer experience overall (Macmillan, 2017).
Changes to the Quality Outcomes Framework for cancer
Following a national consultation by NICE (2020), changes to the Quality and Outcomes Framework (QOF) for cancer have come into place from 1 April 2021 (Table 2). These changes provide an opportunity to improve the quality of cancer care reviews and improve cancer patients' experiences.
Table 2. Quality and Outcomes Framework (QOF) indicators for cancer
| Cancer QOF | Criteria | Points | Range |
|---|---|---|---|
| New CAN005 | The percentage of patients with cancer, diagnosed within the preceding 12 months, who have had the opportunity for a discussion and informed of the support available from primary care, within 3 months of diagnosis | 2 | 70-90% |
| CAN004 | The percentage of patients with cancer, diagnosed within the preceding 24 months, who have a patient Cancer Care Review using a structured template within 12 months of diagnosis | 6 | 50-90% |
A contact within 3 months of being diagnosed will provide an opportunity for primary care teams to offer support and signpost to relevant services or a social prescriber.
The requirement to offer a cancer care review up to 12 months after diagnosis enables this to be conducted at the end of treatment for most patients. The requirement for Macmillan's template to be used promotes a comprehensive and holistic review. Macmillan have produced a useful top ten tips for cancer care reviews (https://www.macmillan.org.uk/healthcare-professionals/news-and-resources/guides/ten-tips-primary-care-cancer-care-reviews) and includes preparing the patient for the consultation. This enables the patient to identify areas of concern for the consultation.
The role of general practice nurses in cancer care
Although general practice nurses are leaders in the provision of LTC care, cancer care reviews have largely remained the domain of GPs according to the reporting from a Macmillan Funded project in South West London in 2019 led by the author (South West London Health and Care Partnership, 2019). Patient focus groups identified that the quality of these reviews has varied largely, with many patients feeling the reviews had not met their needs. This is corroborated by the NICE (2020) cancer QOF consultation, where both individuals and organisations shared their views.
The revised QOF criteria provides an opportunity to improve the quality of these interventions through the changes in the criteria and, it could be argued, through a shift in provision to primary care nurses. Nursing practice is rooted in holistic assessment and care, and primary care nurses use these skills to expertly care for patients with LTCs from asthma to diabetes to heart failure: why not cancer?
Education and training for nurses on cancer is an important consideration. A training needs analysis in the South West London project led by the author demonstrated that 70% of nurses had not received any undergraduate or post-registration training on cancer. There is an urgent need to include cancer on the curriculum for post-registration programmes and for nurses to be included in primary care education on cancer.
Macmillan provide opportunities for practice nurse education on cancer (see useful resources). Nurses need to be supported to develop their clinical expertise and clinical leadership around cancer – in London general practice nurses can join the Cancer GPN Community of Practice (contact the author: Sandra.Dyer1@nhs.net).
Conclusion
Improving cancer care in primary care so that patients report they feel well supported is a strong driver for quality improvement. Opportunities for general practice nurses to lead on quality improvement in this area include:
- Opportunistic conversations with patients about their cancer when they attend for other LTC reviews or other reasons
- Becoming practice lead for cancer care reviews
- Being a visible point of contact for cancer patients at their practice.
A move to incorporate cancer into the day-to-day business of general practice nursing would, in the author's view, improve both patient experience and outcomes. The recent QOF changes make this the ideal time for a change in practice!
Useful resources
Macmillan practice nurse course. This free to access course has now been relaunched. More details are here: https://vimeo.com/546490426/1d722247ae or email: serviceopssupport@macmillan.org.uk
Macmillan resources for professionals – Cancer care review: https://www.macmillan.org.uk/healthcare-professionals/cancer-pathways/prevention-and-diagnosis/cancer-care-review
KEY POINTS
- With increasing numbers of those living with and beyond cancer, there is a greater need for models of care that best meet the needs of those who are surviving, with the role of primary care becoming increasingly important
- For many, cancer has transitioned to a long-term condition
- Data show that only 39.1% of patients definitely felt well supported by their GP or practice nurse during their cancer treatment
- There is an urgent need to include cancer on the curriculum for post-registration programmes and for nurses to be included in primary care education on cancer
CPD reflective practice
- Why is cancer now deemed to be a long-term condition for many people?
- How is cancer care managed in your practice? Do you think the current way of working is optimal for patients?
- What role could you play in improving care for cancer patients at your practice?