Macmillan Nurse Consultant-Breast Cancer
Berkshire Cancer Centre
Royal Berkshire NHS Foundation Trust
The Berkshire Cancer Centre in Reading is one of two cancer centres in the Thames Valley Cancer Alliance area/region providing cancer services to people across Berkshire and areas of South Oxfordshire. Breast Care is the largest service within the Centre and the number of patients has increased over the last five years with 555 patients diagnosed with new primary breast cancer in 2021.
In addition, there are approximately 211 patients with metastatic breast cancer in the overall Cancer Nurse Specialist (CNS) caseload.
In January 2022 there were 1339 breast cancer patients being monitored and reviewed on the Open Access Follow Up (OAFU) pathway which is the patient-initiated post treatment follow up. (In comparison there are approximately 600 current patients with colorectal cancer on their OAFU)
This has led the Centre to review the breast patient cancer pathway and the cancer nursing and other staffing to support this demand.
The Breast Care Service
The Breast Care Service comprises of two band 6 Cancer Nurse Specialists, 2.5 band 7 Clinical Nurse Specialists and one Macmillan Nurse Consultant-Breast Cancer. There are two band 4 Cancer Support Workers who support the Open Access Pathway and CNS working. The Breast Care Service is currently looking to expand, with business cases in progress, for two further CNS posts to build on the range of services that can be offered. The team would like to be able to deliver a specific clinic on the menopausal side effects of endocrine treatment and on breast reconstruction-surgical pain. Currently the staffing levels lend themselves to covering core priorities only. Like many CNS services the Breast Care Service has an increasingly aging workforce with many specialist nurses approaching retirement age. This will impact on future skills and service delivery.
What action was taken to address the issue?
A service training needs pathway is being undertaken to look at specific skills required by the Breast Care Service as well as by individual staff. One of the differences between the CNS band 6 and CNS band 7 is the acquisition of higher-level clinical decision-making skills. Band 6 CNSs need to develop experience in care and treatment of the breast cancer patients as well as undertake training education at post-graduate level and in advanced communication skills. Clinical leadership and assertiveness are also necessary skills for all CNSs. Advanced skills may include physical assessment and clinical decision-making skills and prescribing. There are continual challenges around staff release, backfill and funding.
There is recognition within the Cancer Centre, that work is needed within the Trust to attract band 5 nursing roles to see the value and reward of working in cancer services and develop a cancer nursing pathway offering attractive roles to recruit and retain staff. This is also recognised at a regional and national level.
The Cancer Nurse Consultant role
In the Royal Berkshire NHS Foundation Trust Breast Service, Catherine Bailey is the Cancer Nurse Consultant initially funded via Macmillan Cancer Support. This 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 at an independent autonomous level, with advanced clinical decision –making and a non-medical prescribing role. In the Berkshire Cancer Centre, 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’’.
Education and training for the Cancer Nurse Consultant role
Education and training for the Nurse Consultant role can vary between different post-holders, but the current post holder has extensive experience in the CNS role, a degree in Oncology, frontline leadership skills, prescribing and advanced clinical assessment skills and advanced clinical decision-making obtained through experience and post graduate studies. She is also applying for a PHD to extend her knowledge and 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.
Implementing an Open Access Follow Up (OAFU) Pathway
One of the important aspects Catherine oversees in the Breast Cancer Service was the implementation of the Open Access Follow Up pathway (OAFU). This is a new type of follow-up. With the Open Access 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 Nurse Consultant has oversight of this pathway
Patients can call the Breast Cancer Service when they have a problem. Open Access is run by a Band 4 Cancer Support Worker which is a key administrative role and helps free up CNS time.
In the past, patients who had completed their treatment for early breast cancer were seen for follow-up by their consultant team in the hospital. Although some patients found these appointments useful and reassuring, many patients found coming to the hospital a source of great anxiety and not particularly helpful. There is also good evidence to show that following up patients in this way does not prevent cancer returning and does not increase the life expectancy of patients. So, the positives of Open Access are reduced appointments for the patient, and this frees up CNS and consultant time for the new referrals and people with ongoing treatment concerns.
Previously this was also seen as ‘managing the database of patients’ rather than a patient self-management pathway, with the patient and the CNS at the centre. Following up patients when they transfer to surveillance is crucial, so they don’t get lost in the system. Once patients are on the OAFU a treatment summary is compiled and a letter sent to them and copied to their GP. This outlines the type of cancer they had, a summary of their treatment including endocrine therapy and recommendations for surveillance including mammograms and DEXA scans if needed. They are also given a discharge date. Within the letter are codes to encourage the GP to undertake a ‘cancer care review’. Included with the letter is a ‘signs and symptoms’ leaflet detailing how the patient can access the Breast CNS Team if they have any concerns – they can have prompt re-access to the Breast Care Service if required.
They will also be invited to an endocrine workshop run by the Nurse Consultant if they are on this treatment to explain about the treatment, any side effects and self-care measures. After three months patients will be offered a holistic needs assessment as part of the NHS personalised care agenda where their needs and concerns will be discussed. The patient has a care plan to develop self-care and signposting to services such as primary care, rehabilitation, the wellbeing team and local social care services as appropriate so they do not feel that they are just ‘left’ and that there is a transition between secondary and primary care.
Discharge is usually 5 years and patients can ring the CNS in this time if they have concerns in addition to having their annual mammogram. The Band 4 Cancer Support Worker sends out mammogram results letters within a week and is the front-line telephone contact for patients. The feedback on this has been excellent as people appreciate a prompt response to reduce anxiety. The system also will flag up at 14 months if someone has not received or attended their annual mammogram which the Cancer Support Worker monitors. The Nurse Consultant follows up patients with an abnormal scan-again reducing the waiting time for the patient.
The Nurse Consultant oversees the governance of this system and links closely with the Rheumatology Department who undertake the bone density scans required for patients having endocrine treatment and a joint letter is sent to the patient with results.
What benefits have resulted from the Cancer Nurse Consultant role?
The Cancer Nurse Consultant 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. CNSs and other service staff appreciate this lead role for mentorship and support.
The Open Access approach, as well as the role in the cancer clinics has freed up consultant time so they can concentrate on other key aspects of their roles and gives the patient an improved service.
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.
‘’It’s important to have good working links with other services in the Cancer Centre and across the Trust and externally across the Thames Valley Cancer Alliance area. I sit on the Chemotherapy Steering Group, the Thames Valley Lead Cancer Nurse Group and the Clinical Commissioning Cancer Group to ensure the current needs of the breast and cancer services and patients are being raised and to share our own good practice and learn about anything new to help inform our service.’’
Catherine Bailey, Macmillan Nurse Consultant – Breast Cancer, Berkshire Cancer Centre
Catherine Bailey, Macmillan Nurse Consultant – Breast Cancer, Berkshire Cancer Centre firstname.lastname@example.org