Katie Hunter, Dorset Cancer Partnership Cancer Services Coordinator at Dorset Clinical Commissioning Group has a wide remit which includes patient and public involvement. Katie came to Help and Care at the invitation of Sue Newell, Wessex Voices Project Lead to meet Jo Lee and Kathleen Gillett the coordinators of Dorset Macmillan Advocacy having already met colleagues at Dorset Advocacy.
Katie explained Dorset Cancer Partnership’s plans for improving cancer services in the county and we went on to discuss how volunteer advocates and advocacy partners might be able to share their views. Katie has already met with the chair of Dorset Macmillan Advocacy’s steering group, Cancer in Older People’s Development Group, and two peer volunteer advocates but will attend a future volunteer team meeting to hear more about why and how people affected by cancer are providing advocacy support and what they get out of it.
Kathleen and Jo suggested that volunteer advocates can often see immediate benefits of the help they are giving whereas taking action to improve cancer services can require a more long term view. Katie will be able to ask the volunteers how they would like to participate in the newly developed local involvement opportunities.
Research and technological advances mean that new cancer treatments are continually coming on stream. This is good to know given that the number of people living with a cancer diagnosis in the UK is set to double from more than 2 million in 2010 to 4 million by 2030. But what about the people who actually help those affected by cancer, doctors and nurses for example. How is the cancer workforce keeping up with change and preparing for the future?
In February of this year Thinking Differently Macmillan’s vision for the future cancer workforce in England was published. In the Foreword Dr Fran Woodard, Executive Director of Policy and Impact, states: ‘We believe that the workforce needs to be equipped with the capacity, confidence and skills to identify and address holistic needs, to tailor follow-up care and support people to self-manage.’
The current challenges facing the cancer workforce include:
rising demand for services and increasing complexity – e.g. people living with multiple long term conditions
poor coordination and communication leading to lack of support for recovery
Macmillan calls on Health Education England and the NHS at national, regional and local level to work strategically to ensure people living with cancer experience well-coordinated continuity of care: ‘Our vision is for a workforce that can deliver holistic, patient-centred care and support. It is based on understanding the needs of people living with cancer and the access they need to other services that will contribute to their care.’
The report explains that ‘Delivering truly patient-centred care means ensuring that people are supported before, during and after treatment… Without the right workforce in place, they … may not have the support they need to optimise their quality of life after treatment. They may not always know who to contact for support nor how best to do so. We know they do not always have enough time to talk through all their concerns or be supported with non-clinical issues, such as financial support.’
Macmillan recognises that ‘Volunteers and people affected by cancer, including carers, also have an important part to play in the cancer care team’. My personal view is that highly trained professionals can fail to see the full potential of volunteers. Peer volunteer advocates are entirely patient or person-centred in their approach as the very nature of advocacy demands that it is led by the service user or advocacy partner as we prefer to call them. Volunteer advocates specialise in finding things out, sourcing additional support and facilitating ways to access that support. Volunteer advocates have time to listen and to build a trusting relationship. Volunteer advocates will not offer clinical support but they will help to ensure people can understand information that they are given and feel ready to make informed choices about treatment and care as well as exploring practical and financial support needs.
The report goes on to say ‘Encouraging retention of staff will also be hugely important, as will looking at the potential of retired professionals as volunteers.’ In Dorset we have proven that staff who reach retirement age can be retained in the workforce by the offer of challenging and rewarding volunteer roles such as providing independent advocacy support. Time our Gift to You includes the stories of several former health professionals. Mike Goodman, retired Clinical Nurse Specialist from Dorset Macmillan Advocacy rightly observes: ‘After many years as a health professional you do build up a wealth of expertise and numerous medical contacts which it seems a waste to suddenly abandon just because you retire.’
The Macmillan report recommends next steps and advises that ‘Solutions will be unique to each local context and will require the input of a variety of local stakeholders, including Cancer Alliances, Sustainability & Transformation Plans and local NHS providers.’ We are trying to help colleagues in statutory services in Dorset to understand what trained peer volunteer advocates can do and how they are contributing to the skill mix of the cancer care workforce for the benefit of people affected by cancer locally.
Kathleen Gillett, Macmillan Project Coordinator, Dorset Macmillan Advocacy, Help & Care
The working group argues that ‘currently there is a negative cycle in cancer care, where a short-term approach leads to rising costs in cancer, makes fewer resources available, provides inadequate patient support which re-enforces the need for a short-term ‘just managing’ approach.’ It proposes ways to break the negative cycle.
To address this challenge, The Patients Association and Bristol-Myers Squibb are working alongside experts and patients from across the cancer space to identify new models of service delivery, showcase best practice, and provide real improvements in patient care.
The report discussion includes sections and recommendations on:
Identifying, incentivising and implementing best practice
Developing effective prevention strategies
Implementing best practice in the early diagnosis of cancer
Delivering timely access to treatment
Engaging patients in delivering innovative care pathways
To my mind the report blurs the issue of patient engagement and involvement in service improvement and that of individual patients who are ‘engaged’ and active in their own healthcare journey. Both are important and worthwhile while distinct from each other.
I think that the argument for ‘engaging patients in delivering innovative care pathways’ reads like a explanation of the benefits of independent advocacy support:
‘Educating patients with cancer about self-management and empowering them to play an active role in the decision-making process was considered to likely result in an improvement of patients’ knowledge, understanding of their condition, adherence to treatment and engagement in their healthcare. Whilst not all patients will want to play an active role in their treatment and care, it is important to provide patients with the opportunity and the choice to make their preferences clear and also tell us what a “good” treatment outcome looks like for them.
‘The Working Group described these users as “activated patients” who can lead the charge for the adoption of best practice care. According to Working Group attendees, the evidence suggests that “activated” and informed patients use an average of 20% fewer resources than less informed counterparts.’
Advocacy support is unfortunately still relatively unknown and it is not uncommon to read policy reports in both health and social care spheres that appear to describe it and recommend it without ever using the term. I believe that independent advocacy support and particularly that provided by peer volunteer advocates has a role to play in breaking the negative cycle of cancer care. It can certainly be preventative and facilitate timely access to treatment in addition to empowering patients. I would like to see it recognised as an integral part of the cancer care pathway, recognised as best practice and implemented nationally.
Today we hear from Emily Brown, Interim volunteer manager and independent advocate at Dorset Macmillan Advocacy:
I am new to Dorset Macmillan Advocacy service, not to Dorset Advocacy, but I am a newby on this project. I have been blown away by the dedication given to it by staff at Help and Care and Dorset Advocacy, the members of our Cancer in Older People Development Group and of course by all of those volunteers who give their precious time and share and draw from their own experiences in order to support those that need it. I have come at an exciting and challenging time as we strive to illustrate the benefits, positive outcomes and impact of the service on the people we support…we know the impacts because advocates see this first hand, but how do we convey its importance to others when times are tough, and how do we show that advocacy can also be a benefit to the NHS?
Jenny Purcell and Karen Piggott of Dorset Advocacy were invited to speak at the Clinical Commissioning Group’s (CCG) lung cancer pathways information day last month. They presented to a number of professionals on the benefits and impact of advocacy. We often talk about the benefits of advocacy for the individual which is, without doubt, the most important thing but what is not always considered are the benefits of advocacy for the service providers.
We have recently received an independent evaluation of our service which illustrates exactly this. Essentially what the evaluation does is highlight how the introduction of advocacy support can help to ensure that the choices that the person makes are well informed, that the individual has a consistent person throughout their journey, and that as a result the input of advocacy can help the process to move more swiftly, advocates can ensure that people can keep to their appointments and that the individual’s other concerns are being addressed allowing them to focus on decisions about treatment.
In fact there was a recent example with one of our cases when a health professional at Dorset County Hospital postponed an appointment by a few days in order for an advocate to be able to meet their partner and attend this appointment with the patient. This action alone indicates to me that this health professional recognised the value in having an advocate present to support at the appointment.
Our work continues with the CCG in Dorset to initiate the introduction of advocacy as a recognised standard of good practice on the lung cancer pathway. We are not there yet but the evaluation along with our Case for Support will, we hope, enable us to convey the impact of advocacy and put together a pilot scheme that can illustrate the values of the service for the service providers as well as those who receive it.
Bob Smith, volunteer advocate, and Kathleen Gillett of Dorset Macmillan Advocacy attended the recent ‘Dorset Cancer Alliance 2016 and Beyond’ conference.
The Dorset Cancer Alliance (DCA) comprises the three Dorset NHS Foundation Trusts, the Dorset Clinical Commissioning Group and the Dorset Cancer Patients Group. The other volunteers who attended and brought the patient perspective were Paul Grant, Trustee of Living Tree Bridport, and three members of Dorset Cancer Patient Group including group chair Emma Willis.
Emma (who is also Director and Founder of Shine Cancer Support) made a presentation on Improving Cancer Patient Experience. Emma concluded ‘we need to be more challenging and more brave in involving patients at higher levels, ask for more from patient representatives, ask the question ‘How can I utilise the experience of patients to help with this?’ aiming to build strong and inclusive patient involvement in cancer services.
Emma Willis and Bob Smith
The Dorset team for Macmillan Cancer Support was there. Paula Bond, Macmillan Development Manager, has been instrumental in arranging funding for several services (including the advocacy service) and research/scoping projects locally, and Tracy Street, Macmillan Involvement Coordinator, has given capacity building support and guidance to Dorset Cancer Patient Group and to the independent cancer self help and support groups.
It was a full afternoon which included presentations from clinicians, commissioners and representatives of the Wessex Strategic Clinical Network. We considered the current situation in Dorset and related it to the Wessex and the National Cancer Strategy. Another factor in Dorset to take in to account is the current Clinical Services Review by the CCG.
Breakout groups discussed the different stages of the cancer journey and priorities for improvement. One group focussed on patient experience and chose ‘Communication’ as the main priority: Both ‘how people are communicated with’ and ‘what information is communicated’. We heard an example of a patient receiving their diagnosis in a way that left them both shocked and confused. Macmillan GP Lavina Sakhrani-Clarke was interested to discuss the idea of letters from secondary care clinicians traditionally sent to GPs actually being addressed to the patient instead and written in layman’s terms. The GP would still be copied in and would, she felt, have a better chance of understanding the content.
Paul Grant and Bob Smith
Kathleen explained to the discussion group how volunteer advocates can support people at appointments and in understanding the content and implications of the letters they are sent. Some advocacy partners that we have supported in Dorset have told us they were afraid to read their letters or printed information, keeping them tucked away out of sight, until they had their advocate with them to discuss the contents.
In today’s blog post Kathleen Gillett from Dorset Macmillan Advocacy looks at the issues facing older people affected by other long term conditions as well as cancer:
Coping with cancer is one thing, coping with cancer and one or more other long term condition is another. Peer advocates listen to the people they support to discover what matters most to them and may be surprised to find that having cancer can be the least of their worries.
At Dorset Macmillan Advocacy we have collected some information on the long term conditions and health problems that the people we are supporting are living with. We have found that of 110 people referred to us for support in 2015 50 have at least one other long term condition, 26 have two conditions including drug and alcohol dependency issues and 7 have 3 conditions. The conditions include sensory loss, diabetes, heart condition, memory problems, arthritis, MS, ME, epilepsy, hiatus hernia and mental health issues. Not everyone wants to disclose all their health issues and we have not in every case methodically recorded where this information has been given so I think it is safe to say that there are likely to be more issues than we actually know of.
In fact 70% of people with cancer have one or more additional long term condition according to research carried out by Macmillan Cancer Support. It’s clear that the situation for people with limited social support networks, such as older people, can be very difficult. Independent advocacy services such as ours can be flexible and support people with their concerns when they are wider and more complex than the cancer diagnosis.
Health professionals are aware of the implications especially as regards treatment options for older people. The British Geriatric Society has a special interest group (SIG) for Oncology which met for the first time last September and Kath Parson of OPAAL gave a presentation about the Cancer, Older People and Advocacy programme. In a write-up of that event Dr Lucy Dumas said ‘Older patients with multiple medical co-morbidities and/or issues with care or coping at home represent a significant challenge when it comes to evaluating whether or not they will be able to tolerate potentially toxic therapies’.
Over the next year we hope to gather more information about the wider health issues of the people that we support. As well as asking for their feedback on the difference our service has made we may be able to gather their views on how their other conditions have impacted on their cancer patient experience.
In this post Helen Vernon, advocate at Sefton Pensioners Advocacy Centre (SPAC), talks about collaboration, compassion, choice and advocacy:
In February I attended an excellent conference called Palliative End of Life Care: Collaboration, Compassion, Choice. The event was attended by a wide range of interested parties including commissioners, consultants, GP’s, nurses and members of the voluntary sector.
One interesting thing that almost every speaker opted to do was to relate their speech to their own personal experience of losing a family member. This had been the motivation for each of them to follow their career path, either because the experience had been so poor or because they wanted to replicate a positive experience for others.
There were several key pieces of information that came out of the day and I have attempted to summarise some of these below.
The keynote speaker was Jacquie White who is the Deputy Director for Long Term Conditions in NHS England with responsibility for improving the quality of life and experience of end of life care for people with Long Term Conditions and their carers. As part of her presentation she showed this slide about the six ambitions she would like health and care professionals to sign up to to achieve improvements in care. There are obvious links between these ambitions and advocacy.
Jacquie also spoke about their plans to develop an “orientation” process for people who have been diagnosed with a long term condition and she described it as a ‘how to’ for living with that condition. If this became the norm there must surely be a place for advocacy within this programme.
Alison Colclough from St Luke’s Hospice in Chester spoke about their homelessness project and whether people who are street homeless get choice at the end of their life. This also resonated strongly with our advocacy work and it made me consider whether we have explored this sufficiently when we are promoting our service.
The theme of collaboration ran strongly throughout the day and there was a lot of advice about how this could be achieved. There were stories of success and advice about approaches to improving inter agency working. Annamarie Challinor, Head of Service Development (Macmillan) for The End of Life Project shared this image with us, which we could use as a visual reminder of how broadly we are promoting the COPA project.
Helen Vernon, Advocate, Sefton Pensioners Advocacy Centre (SPAC)
Malcolm joined Dorset Macmillan Advocacy as a Peer Advocate early in 2015. With personal experience of cancer and of training people in a commercial environment, we were pleased to welcome him to the team.
When it came to looking for candidates to put forward for the OPAAL/Sanofi Train the Trainer project, Malcolm was a natural choice.
Here Malcolm relates his training and also his first experience of putting it into action when he attended a Macmillan Bitesize event at Dorchester County Hospital in November 2015.
“Initially as volunteers we were invited to a training session both to develop our skills in delivery and also to share our experiences of bereavement and cancer at first hand; both what you yourself had experienced and also the effects cancer had had on service users you had encountered whether on their health/wellbeing, employment, relationships and a new attitude to life in general.
Cancer had figured as a central issue to a particular client that I had been supporting; coming to terms with the treatments and after-effects and how relatives, friends and work colleagues viewed the client pre and post treatment.
The training aimed to prepare volunteers for speaking to health care professionals about both personal and client experiences of cancer and recovery.
The first event I attended as a Trainer was held on the 16th November 2015 at Dorset County Hospital in Dorchester.
The objective was to provide a group of health care staff with first-hand experience of the viewpoints of volunteers supporting advocacy partners.
I shared a story about an advocacy partner who was recovering from cancer and wanted to return to work. We spoke about how I worked with her to understand her requirements and what she would ideally prefer to do, as her work was a physical post. Together we produced a strategy that she was able to present to her employers.
The talk appeared to be well received by the audience, possibly providing them with food for thought.
Feedback gleaned from the event included positive comments about how useful it was to hear from previous patients and also to have heard the advocacy stories direct from the Peer Advocates themselves demonstrating how powerful it is to hear evidence from the people not only who have personal experience of cancer but who have come forward to support others using their own experience and skills.”
“We want to have the best cancer care. Anywhere.”
Those were the words of new National Cancer Director Cally Palmer CBE as she addressed attendees to the Britain Against Cancer conference hosted yesterday in London by the All Party Parliamentary Group on Cancer (APPGC).
The annual event, which featured a keynote speech by Secretary of State Jeremy Hunt and was also attended by NHS England’s National Clinical Director for Cancer Professor Sean Duffy, is one of is one of the largest conferences of its kind in the UK.
Miss Palmer, who is Chief Executive of the Royal Marsden Hospital NHS Foundation Trust and joined NHS England as National Cancer Director in November, praised the vision set out by the Independent Cancer Taskforce and outlined some of the ways she will lead implementation of the recommendations of its report.
Miss Palmer said: “Back in September NHS England announced a new ‘Cancer Vanguard’: three sites which will come together to trial new ideas and approaches to the commissioning and provision of cancer services, including testing capitated budgets from April 2017. We expect this to begin to teach us about what works and what doesn’t almost immediately.”
“In response to the recommendation by the Taskforce report, we’re also establishing Cancer Alliances across the country from April next year, which will be the cornerstone of delivering changes at a local level.”
Miss Palmer announced a new Cancer Transformation Board to lead the rollout of the other recommendations of the Taskforce report, and a Cancer Advisory Group, chaired by Harpal Kumar, Chief Executive of Cancer Research UK, to oversee and scrutinise their work.
Miss Palmer also presented the first prototype of a new Cancer Dashboard to measure progress with a focus on incidence, survival rates, patient experience and quality of life for patients.
“From April 2016 every CCG will be able to see their own data in this format and will be able to benchmark themselves against other CCGs.
“This was the first of the 96 recommendations that the Taskforce gave us, and we have made it a priority. We all need to be clear what we’re working towards, and a unified set of measures is fundamental to this.”
OPAAL welcomes these initiatives and looks forward to collaborating with Macmillan on their roll out, in particular discussions around influencing the new Cancer Alliances across the country from April 2016.
In this blog post Pamela Hill, OPAAL‘s newest National Development Officer, tells us about cascading information to our Primary Care colleagues:
I recently spent two days representing OPAAL at the Macmillan Primary Care conference offering information to primary and secondary care delegates through our exhibition stand. What an excellent networking opportunity the event provided. While I wasn’t able to hear any of the speakers, I chatted with a number of Macmillan health care professionals. They were all extremely positive about the event which was intended to explore how those involved in primary and secondary care can work in a more integrated way to provide the best possible outcomes for those people affected by cancer.
Pamela alongside Karen Pierce from delivery partner SPAC
Delegates were very interested in the exhibition stands and many came forward to find out more about the Cancer, Older People and Advocacy programme. It was a good opportunity to convince health care professionals who practice in areas where the project doesn’t already operate that we need them to influence their respective CCG’s by explaining the importance and benefits of advocacy support for older people affected by cancer. Of course, this suggestion was met with the usual response that the CCG’s have no money left in their budgets.
The really good news is that the GP’s from the 14 areas where the service already operates were very positive about their experiences of Cancer, Older People and Advocacy programme. I even managed to persuade one or two GP’s who have experience of the benefits of advocacy support to bring their colleagues along to our stand so they too could learn about more about the Cancer, Older People and Advocacy programme.
During the conference sessions, while the delegates were listening to speakers, I decided to introduce myself to the other exhibitors and they were all keen to explain their work to me. They listened to the information I had to offer about the Cancer, Older People and Advocacy programme and we swapped contact details and information leaflets so that we are better able to signpost and refer. I intend to share the information and leaflets with partners.
Pamela Hill OPAAL and Karen Pierce SPAC
Working across boundaries? Yes, I was heartened to feel it really is happening but we must continue to further develop the partnership approach so that we not only offer an holistic approach to services for those older people affected by cancer but wouldn’t it be a real step forward if we could offer the same services in every area of the UK?
Older People Living with Cancer 