Introducing the Role of Pathway Navigator to the South East Region Cancer Alliances – a current project
The Cancer Alliances in the South East (SE) Region were aware of the success of the role of Pathway Navigator (PN) and how it was supporting trusts to meet the 28 day new Faster Diagnosis Standard (FDS) and the various nationally set cancer waiting times.
The four SE Cancer Alliances: Wessex, Surrey and Sussex, Kent and Medway and Thames Valley compiled and submitted a successful high-level bid for funding to Health Education England in October 2020 for a coordinated approach of implementing 19 new Pathway Navigators within trusts across all four Alliances. This included the cost of the salary and on-costs for 12 months, with the hope that the trusts would adopt the individual posts after this period seeing the value they added to patients and their cancer services. Individual Alliances would agree where the posts were situated.
The high-level bid was compiled which set out plans to:
- develop a formal approach to the development and deployment of cross system navigation to support cancer pathways through COVID-19 pandemic response and beyond.
- Align the variation of the job description, training, competencies, skill set and career progression across the Alliances with this project aiming to support the standardisation across SE where possible.
- The impact of the new roles will be evaluated and measured against agreed baseline data and used to evidence the potential added value of these roles and become part of the cancer workforce.
Whilst each Alliance oversees the project in their geography, the overarching project has been managed by NHS England and Improvement South East to support the standardisation and evaluation on a SE wide level.
This is an ongoing project and in the early stages of implementation with recruitment still in progress at the time of writing this case study. The evaluation of the role is only possible once the PNs have been in the role for some time.
What was the issue/problem that needed to be addressed?
There were several issues which needed to be addressed:
- Prior to the COVID-19 pandemic, national demand for diagnostic services had risen rapidly over the past five years and is continuing to grow.
- The pandemic has exacerbated the pre-existing problems in diagnostic services and an increase in diagnostic capacity is required to reduce this backlog and meet the future demand for these services.
- Changes are needed to comply with the 28-day Faster Diagnosis Standard which needs more streamlined and efficient pathways.
- The collaboration of specialist services and different care settings is needed – support and information for the patient on the pathway is critical and also needs closer working between primary (GP), secondary (District General Hospitals) and tertiary care settings.
- The South East Cancer Alliances identified that a key workforce role to support the 28- day FDS pathway (time from referral to diagnosis/ruling out cancer) is that of the Pathway Navigator who works along patient pathways and across services.
What is the Pathway Navigator role?
The Pathway Navigator (PN) role can vary between trusts and, as the title suggests, navigates patients through all or discrete parts of the cancer pathway from a referral with suspected cancer to a confirmed cancer diagnosis or ruling out of cancer to enable the trust to meet the 28-day Faster Diagnosis Standard (FDS) target whilst also helping to meet the 2-week wait, 31-day and 62-day targets.
The role acts as a single and consistent point of contact to patients, using their skills to work with the multi-disciplinary team (MDT) and other key stakeholders to ensure patients are moved smoothly through their diagnostic pathways. They actively coordinate booking of appointments for the patient and manage any potential breaches of the Cancer Waiting Times (CWT). This includes initiating action with other trust colleagues/teams to ensure the CWT targets are met.
The PN needs to be an organised and effective administrator with a good knowledge of different software programmes and have a sensitive and compassionate approach, excellent communication and customer service skills to ensure patients receive first-class care and support and enable them to have the best possible experience throughout their pathway.
Requirements for the Navigator Role will vary but generally include:
- educated to ‘A ’level or degree level or equivalent level of appropriate work experience
- hold an administration qualification or equivalent level of appropriate work experience
- have experience in an NHS or medical setting usually in an administrative role
- have excellent IT skills using a range of software, data manipulation and experience of using hospital systems
- experience of working in a multi-disciplinary team, and on own
- good communication and organisational skills.
Although over 90% of patients will not have a diagnosis of cancer the fact that an estimated 1 in 2 people will get cancer in their lifetime means that they will, in all probability, be ‘returning customers’. Therefore, they need to be reassured by, and at, each contact. Specific role training is provided ‘on the job’ as well as through a database of training available to the PNs. This database aims to cover each competency element and will be updated as the project progresses based on feedback from the PNs and colleagues around them.
As this is a relatively new role there is some variation in implementation, in the role title and there are also differences in the pay band depending on the skills and competencies required, but generally this is a band 4 or 5 role.
Some specific examples of a Cancer Navigator role
The Vague and Indeterminate Symptoms Service (VISS) Pathway Navigator
A Vague and Indeterminate Symptoms Service (VISS) utilises a Pathway Navigator to support the pathway which aims to help streamline the investigative and diagnostic processes for patients who keep presenting to their GPs with vague symptoms that need prompt investigation for a possible cancer.
The VISS Pathway Navigator supports and facilitates a co-ordinated patient experience focusing on improving the support and tracking of the patient through their diagnostics, treatment plans and investigations. They work within the multi-disciplinary team to support an uncomplicated rapid pathway.
The role ensures that all cancer target patients are accurately monitored prospectively through each stage of their diagnostic and treatment pathway and supports trust MDT Co-ordinators, Two Week Wait Appointment Officers and the Early Diagnosis Administrators to:
- supervise the prospective management of patients referred on the Two Week Wait pathway for suspected cancer liaising with departmental managers and senior clinicians regarding capacity for outpatient appointments and diagnostic testing, to ensure all patients are seen within the 2-week standard, whilst aiming for a 7 day standard.
- proactively manage the beginning of the pathway for diagnostics to ensure all patients are appointed within 2-5 days for all investigations where possible for all tumour sites to enable the Trust to meet the 28-day Faster Diagnosis Standard target.
The Early Diagnosis Administrator will then also liaise with the Theatre Scheduling department and General Manager for Surgery to ensure patients are treated within the 31 and 62-day targets.
The VISS Pathway Navigator will support the Cancer Patient Pathway Lead to help resolve any delays or problems within the patient cancer pathways and processes to ensure that the trust achieves all the Cancer Waiting Times targets.
The role supports clinical teams in primary and secondary care, liaising with referring General Practices for additional or missing information in referrals, sending correspondence to patients about the service they have been referred for and bridging the gap between referral at primary care and management in secondary care. This requires effective working relationships with MDT Leads, MDT Co-Ordinators, Clinical Nurse Specialists, Theatre Scheduling, Radiology, Pathology and service providers to ensure all patients are actively managed by the relevant teams to prevent patients breaching their Cancer Waiting Time Targets
Their role includes providing the administrative duties required to book appointments and transcribe clinic letters to aid effective communication and may also include maintaining the VISS dataset and liaising with the local Cancer Alliance and other external bodies to ensure processes are in place for the collection of data. They also need to be able to negotiate with all Multi-Disciplinary Team members across all relevant trusts and organisations to agree and accurately record the sensitive and complex data related to cancer diagnosis and treatment plans.
*To note -VISS will be undergoing change as the service is linked to Rapid Diagnostic Centres which are being replaced by a new Faster Diagnosis Framework and Community Diagnostic Hubs, so the Pathway Navigator role is subject to change. As this is a relatively new role there is, as yet no evaluation of its impact on the cancer pathway.
Lower Gastro-Intestinal Cancer (LGI) Cancer Navigator Role
The Lower Gastro-Intestinal Cancer (LGI) Navigator Role provides a professional, proactive and sensitive service to patients referred on a 62-day cancer pathway for suspected Lower Gastro-intestinal cancer (LGI). The role is a main point of contact for patients, carers and the wider healthcare team, including primary, secondary and tertiary services. They are an integral member of the LGI team, working in partnership with the specialist nurses, clinicians and cancer services to ensure patients are fully informed and supported, and the pathway is coordinated by proactively tracking timelines through the diagnostic pathway. The LGI Cancer Pathway Navigator is responsible for the coordination of the administrative function of the pathway, including arranging investigations, booking appointments, multi-disciplinary team (MDT) discussions, and keeping patients informed at all times. Through effective and efficient patient focused co-ordination of the pathway, patients will be given a diagnosis or exclusion of cancer at the earliest opportunity.
The LGI Cancer Pathway Navigator co-ordinates the LGI pathway from referral to treatment and initially on receiving the two -week wait referral will engage with the patient as a single point of contact. They will then ensure that the referral is recorded on trust systems and communicate with nursing and clinical teams so that a patient is added on the internal tracking list and is tracked daily liaising with cancer services for purposes of the 62-day target.
They will ensure the referral information, patient letters and any other relevant clinical information including performance status, frailty score and recent blood tests are available for first clinical vetting and assessment liaising with primary care, trust colleagues and diagnostic services and the patient to also ensure a faecal immunochemical test (FIT) is completed and the results accessible.
The role will then work closely with administrative, diagnostic and clinical team colleagues to proactively identify situations where dates of diagnostic tests and treatment may not be scheduled appropriately, exercising their own judgement and be responsible for ensuring appointments and procedures are expedited as necessary and to escalate and resolve issues that may lead to standard failures. This will include identifying patients who are at risk of breaching the pathway milestones and standards and escalate appropriately to enable early and prompt actions to prevent breaches.
The LGI Cancer Pathway Navigator monitors and reviews demand and capacity to mitigate delays in the patient pathway, proactively taking actions and communicating with operational service managers and booking teams to ensure available capacity. They will also assist in organise appointments and scans to mitigate the delay in the patient pathway, ensuring patients
mutually agree the date and time of their appointment within the set time frame, to ensure no-one breaches national targets.
After attending local and specialist multi-disciplinary meetings (MDTs) to understand next steps in the patient pathway the LGI Cancer Pathway Navigator liaises with the clinical teams to determine each individual patient’s next actions, typing up reports of MDT outcomes, ensuring these next actions are scheduled and promptly inform the patient and their carer.
The role will also review the data and analyse trends of the patient pathway, to identify areas requiring improvement, and to contribute to proposals of action as appropriate.
As this is a relatively new role there is, as yet no evaluation of its impact on the cancer pathway.
The South East Cancer Pathway Navigator Project
The South East Cancer Pathway Navigator Project Lead set up a Working Group with the Cancer Alliance project leads which has had several successful outputs including:
- One core job description per Cancer Alliance footprint.
- Core questions about the PN role to be used in any local patient surveys already in existence to avoid duplication.
- ‘Pathway Navigator Portfolio’ for the PNs to record key skills and competencies to assist their training and development and includes sections titled ‘Induction’, ‘Competencies’ and ‘Training and Development record’. This is a working document that is being piloted and will be updated based on feedback from the cancer teams and the PNs themselves.
- Comms piece (attractive job advert and social media content) to promote the PN role and aid recruitment. Development of more material such as ‘a day in the life of’ video is underway.
- Community of Practice workspace has been set up on NHS Futures for PNs to share knowledge, experience and good practice and help with challenges, confidence and personal development.
- Staff survey aimed at Cancer Nurse Specialists (CNS) and other colleagues in the cancer team is being developed as part of qualitative metrics measuring the benefits of the PN role.
What difficulties and barriers needed to be overcome to implement the change?
Implementing a new role can be a challenge for trusts who need the capacity and headspace to introduce the role to existing teams to gain buy in and avoid any potential tension from other staff who may see the new role as a threat to their position for example.
The project has coincided with Covid pressures so Cancer Alliances in the South East region are at differing stages of implementing the project and recruiting to the PN role. Also, the approach of each Alliance is different and the needs of the organisations it covers vary.
Lastly, the recruitment of the PNs for this project (12-month fixed term) has been a huge challenge in some Cancer Alliances often due to the lack of applicants suitable for the job, lengthy HR processes and fierce competition on the job market in general. It is hoped that the comms piece and a promotional video will ease this. Also, once the roles become substantive this could also attract more candidates in the future.
What benefits have resulted from the change?
The full benefits of the South East Cancer Pathway Navigator Project are still to be realised and identified in future evaluation. The benefits of the role may vary across trusts, but based on the experience of organisations who have already implemented, the role is anticipated to:
- Enable Cancer Nurse Specialists (CNSs) to work to the top of their license by freeing up their capacity.
- Assist with reducing ‘Do not Attend Appointments’ (DNAs) thus improving demand and capacity and productivity.
- Assist the trust with the improvement of the FDS and other cancer targets mainly by shortening the time between referral and diagnosis.
- Helping to improve patient care and experience by helping the patient navigate complex NHS systems, keeping them informed and reassured thus reducing anxiety and improving outcomes.
- Helping to improve staff experience and job satisfaction.
The Project will evaluate the role’s impact by looking at baselining the cancer targets before and after the introduction of the PN role as well as analysing responses from the patient and staff surveys. This will then be used to evidence the added value of these roles and the potential benefit of PNs becoming part of the cancer workforce. The Alliances will be working with the trusts on a sustainability plan to ensure roles become part of the workforce in the new model of working. The plan will incorporate recommendations based on the evaluation.
Hints and tips for implementing the PN role
There is a need for a clear understanding of how and where new Pathway Navigator roles can be introduced. Staff in the trusts should be fully briefed about the PN role and where it could be implemented.
It is essential to clarify which cancer pathway, what tasks and functions the role can undertake without duplicating or overlapping with other similar roles eg. the Multi-Disciplinary Team (MDT) Coordinator role and how it can support the trust meeting cancer targets.
It is also vital that a proper induction, ongoing training and development, mentoring and other support for the role is in place.
Lastly, it’s also important to be clear about how and when any funding is allocated to the employing trusts so there is consistency across the Alliances and trusts.
Michaela Uhlhorn, Delivery Manager – SE Cancer Programme, NHS England & NHS Improvement, South East
Bonnie Wyatt, Senior Programme Evaluation Manager – SE Cancer Programme, NHS England & NHS Improvement, South East