Cancer Nursing Pathway and the role of the Cancer Nurse Specialist -Thames Valley Cancer Alliance
Thames Valley Cancer Alliance (TVCA) brings together cancer leaders, commissioners, service providers, people affected by cancer and third sector organisations to take a whole population approach to improving in cancer services across the three Integrated Care Systems of:
- Buckinghamshire, Oxfordshire and Berkshire West ICS (wholly situated within Thames Valley)
- Bath, Swindon and Wiltshire ICS (partly situated)
- Frimley Health and Care (partly situated)
Its aim is to take forward the ambitions in the NHS Long Term Plan, focused on reducing variation, and improving timely access to all cancer services for all people within the Thames Valley.
What was the issue/problem that needed to be addressed?
The national shortage of nurses including cancer nurses is well known. TVCA aims to support the redesign of the cancer nursing pathway, make new and more attractive and alternative role to attract and retain the best workforce. The Alliance believes that staff should be supported particularly due to the pressure of vacancies and increasing demand and has been looking at all cancer nursing and associated roles. The Cancer Nurse Specialist (CNS) has large numbers of staff aged over 50 in the TVCA patch so many may be retiring in the near future and there is a need for a supply pipeline to replace them.
What action was taken to address the issue?
TVCA believes there needs to be a visible cancer nursing (and allied health professional) career progression route from pre-registration nurse through to registered, enhanced, advanced, consultant and strategic leadership. Registered nursing roles commence at Band 5 when the newly qualified nurse will gain experience before progressing into a cancer nursing role, often at band 5 or 6. Trusts are finding that due to the number of nursing vacancies that some progress more quickly so have less experience.
The Cancer Nurse Specialist (CNS) is an established role. supporting a specific tumour site and roles will usually be band 6 or 7 depending on an individual’s experience and competency. The CNS assists the patient with their cancer pathway decision making, providing information and clarity, listening to patient concerns and signposting to other help and services. Many of these roles have been pump-primed by Macmillan Cancer Support with the expectation that the trust will then take on the role. Depending on the setting the CNS role can work across the cancer pathway, undertakes personalised care, more complex treatments and follow up care as patients are living longer with cancer.
TVA recognises that Trusts are unlikely to recruit a CNS with absolutely all the required skills and attributes. CNSs are supported via in-house trust inductions, Macmillan and trust training. In addition, there is an Alliance wide training strategy of support and development working with local universities and trust training departments to assist CNSs to develop and attain the required skills for the role. They can even work towards a master’s degree and some to a first degree if not already obtained. More advanced skills are also offered such as, advanced communication skills, the basics of cancer, breast or other tumour site training, non-medical prescribing and diagnosis. Most are post graduate modules which are offered but the training can vary across trusts due mainly to issues around backfill and release, for example. The strategic aim of CNS development supports the consistency of training which in turn helps services and enables the CNS to progress thus aiding recruitment and retention.
The Alliance believes that there needs to be the right development for cancer nursing and related staff. Trusts need to make the most of HEE funding and the new Aspirant Cancer Career and Education Development programme (ACCEnD) which intends to assist the development of an aspirant cancer career and education programmes for nursing and allied health professionals. The accompanying competency framework is in development for these professions which will help the cancer workforce.
The Alliance has offered some pump-priming funding for pilot projects with the intention that the trusts pick up the on-going funding of the posts, roles or support. An example is TVCA support for a Breast Advanced Clinical Practitioner (ACP) role at Great Western Hospitals NHS Foundation Trust to assist the breast two week wait diagnostic pathway.
The CNS role in a Personalised Care Service
Great Western Hospitals NHS Foundation Trust has gone a step further seeing a gap in the need for more patient support and have set up a new ‘Personalised Care Service’ initially with two-year pump priming funding from Macmillan Cancer Support. This is run by two CNSs -a band 7 Team Lead and a CNS at band 6 who were recruited from the Trust and are passionate about holistic patient care and have initially been seconded to the Service for the two years.
The Personalised Care Service is borne out of the increasing demand on cancer services from new referrals and from people living longer with cancer and in remission so there is less staff time to work with patients including those with more complex needs who require more support. The new Service is available to patients with any type of cancer and at any point in their cancer journey to help empower them to assist self -management and improve their wellbeing. The Service is available in both the community as well as the hospital. Currently the Service offers a variety of services including face-to face sessions as well as virtual workshops on areas such as mindfulness, dealing with cancer fatigue, nutrition and smoking cessation.
A cancer buddying service is also being set up for those who have had a cancer diagnosis within the last five years, or a relative who has closely supported someone in this situation to volunteer to support newly diagnosed patients and those needing more help. There has been a good response from volunteers.
Cancer Services and other cancer staff in the trust are being very supportive and can see the value of the new service.
(The full Case Study on the Macmillan Personalised Care Service run by Cancer Nurse Specialists Michelle Taylor and Lauren McClelland at Great Western Hospitals NHS Foundation Trust is available here)
The CNS Consultant role
The Cancer Nurse Consultant role at band 8 is offered in a number of TVCA trusts and although not all trusts have nurse consultants in cancer care nurse consultants are a recognised role across the NHS in other specialties. It offers a progression route for Cancer Nurse Specialists (CNSs). This advanced role embedded in practice enables care of the patient as an independent autonomous level, with advanced clinical decision –making and a non-medical prescribing role. For example, in the Berkshire Cancer Centre in Reading, the Cancer Nurse Consultant offers clinical leadership and role modelling for the Breast Cancer CNS nursing team.
Responsibilities of the Nurse Consultant in breast cancer include running independent chemotherapy and follow up clinics, giving patients results and discussing treatment options and decisions. The Nurse Consultant leads a multidisciplinary team, comprising of a pharmacist and Lead Chemotherapy Nurse, to undertake Systematic Anti-Cancer Therapy (SACT)/chemotherapy reviews including prescribing of SACT which releases oncologist time.
The Cancer Nurse Consultant runs workshops for Endocrine Treatment and the self-management of side effects and an endocrine treatment clinic. The role ensures prompt follow-ups for patients with abnormal results on their annual mammogram or concerning symptoms and oversees the tracking of patients to ensure that patients are not ‘lost to follow-up’’.
Training and experience for the Consultant Nurse role can vary between different post-holders. This can be extensive experience in the CNS role, having a degree in Oncology, frontline leadership, prescribing, advanced clinical assessment and advanced clinical decision-making skills obtained through post graduate studies.
The role receives positive feedback from patients with a promptness on receiving results, assisting the trust to meet cancer waits and the holistic needs of patients. As there is a national shortage of Consultant Oncologists, the Cancer Nurse Consultant role importantly supports the trust and the workforce to provide these essential skills.
The Nurse Consultant is seen as a ‘role model’ and ensures that there is a specific breast cancer nursing lead in the Centre. Other responsibilities include mentoring staff in the CNS team as well as mentoring those on prescribing courses in the Trust.
Berkshire Cancer Centre has also set up a new type of patient follow up-the Open Access Follow Up pathway (OAFU) which is a key administrative role managed by band 4 Cancer Support Workers and overseen by the Nurse Consultant. With the pathway, the patient stays in the care of the Breast Service for at least five years. They have annual mammogram surveillance and can re-access the Breast Service via the breast CNS/OAFU team. They don’t have routine breast clinic appointments. If a problem is reported on the annual mammogram, they will be brought back into the service for follow up. The positives of Open Access are reduced appointments for the patient, and this frees up CNS and consultant time for the new referral and people with ongoing treatment concerns.
(The full Cancer Nurse Consultant role and Open Access Follow Up pathway is available in a separate Case Study following Catherine Bailey, Macmillan Nurse Consultant,- Breast Cancer, Royal Berkshire NHS Foundation Trust)
What difficulties and barriers needed to be overcome to implement the change?
The biggest challenge is currently a stretched workforce exacerbated by Covid 19. The Alliance needs to carefully find the right opportunity to encourage trusts to look at workforce issues to encourage career pathways, different roles and how skills are delivered. Trusts need headspace to review all this alongside trying to balance multiple demands. There is good practice in place which can be built on and TVCA continues sharing examples of good practice, new roles and approaches via networks and groups.
What benefits have resulted from the change?
There are many positives with different roles coming in to support the cancer pathway and a recognition of more specialist services such as the CNS role, new services and the Cancer Nurse Consultant. Retention in the CNS role has been good. TVCA feel they do well sharing good practice from elsewhere and communicating this to the trusts in their patch via networks and ‘listening’ events. This all supports improved recruitment and retention of staff, the promotion of the cancer career pathway, improving patient experience and helping to meet cancer targets.
Clinical Advisory Groups (CAGS) meet regularly across the Alliance to discuss clinical pathways/services and transformation work to meet the Long-Term Plan. Often within the group workforce challenges are highlighted. With some of the transformation work, additional roles are considered: for example the Nursing Associate (LINK to add in ) and the Navigator role (LINK TO ADD IN). Registered Lead Nurse Forums also share good practice and ideas.
‘’The CNS role really supports an individual and their family at a time of crisis, helps them make decisions and provides support on their cancer pathway which is hugely satisfying’’
Lyndel Moore Lead Cancer Nurse Thames Valley Cancer Alliance
Lyndel Moore Lead Cancer Nurse Thames Valley Cancer Alliance firstname.lastname@example.org