COVID-19 Insight 10: Collaboration among cancer services

In July, we will publish the full report of our provider collaboration review focused on the way local systems have worked to ensure continued provision of cancer services in response to COVID-19. We will share positive practice, people’s experiences, what the challenges have been, and how providers have worked together to overcome those. We will report on access to services and the extent to which people are being seen, how services have tried to improve access and any issues that have arisen, and what we know has happened as a result of changes to services during the COVID-19 pandemic.

Ahead of that publication, we are using this issue of Insight to bring you some examples of the innovation and positive ways in which services in local areas have worked to ensure continued care for people with cancer, or suspected cancer. We are sharing these examples early to support learning and recovery across cancer provision efforts nationally.

This collaboration review about cancer services will follow two previous reviews that looked at the way services have collaborated for people aged over 65, and collaboration in urgent and emergency care.

We wanted to know how the Covid-19 pandemic has affected people’s access to cancer services and their treatment. Our full review of collaboration among cancer services will show how different places and local systems reacted to the challenges of the pandemic. To find out, we have talked to system leaders, individual services and staff, as well as the voluntary sector that provides significant support in people’s cancer care. We will also include examples of people’s experience of these services during the pandemic.

Engaging with local communities

During the Covid-19 pandemic we had concerns about access to health and care services, particularly for people with suspected cancer symptoms. In our review, we asked local health and care systems to share the experiences of the people who use their services, and how providers have dealt with maintaining access to services.

We heard how systems ensured people knew what services were available, including some innovative approaches, and about the work of cancer alliances, system-wide groups which bring together clinical and managerial leaders from different hospital trusts and other health and social care groups. They had been instrumental in communicating that cancer services were still running during the pandemic and that it was extremely important to continue to engage with these services.

Examples of cancer services engaging with communities:

• In one area, the cancer alliance held online chats to educate the public that not all coughs were due to Covid-19, explaining when people should see a GP about possible lung cancer symptoms. Social media has also been used more in various systems. Macmillan Cancer Support used its social media platforms to tell people that primary care services had remained active during the pandemic. One system also used a social media platform to share videos in a variety of languages, voiced by people from local communities, to highlight the importance of attending screening appointments.
• We also heard from systems that prioritised community engagement in response to people’s concerns about contracting Covid-19 whilst seeking medical advice. One system worked closely with community leaders and local faith groups to reassure people about attending hospital and raised awareness of early detection and treatment of cancer. Another system collaborated with a lung health check team and patient advisory group – they created a video to highlight the importance of lung checks through the pandemic and encouraged attendance at appointments. Targeted calls were employed by a separate system, which identified patients at a higher risk for oral cancer, and these patients received personal calls that led to increased attendance for reviews.

Examples of cancer care in response to the pandemic included:

• In Dorset, we heard there was recognition among services that it was important to reduce health inequalities. Services recognised their work around ethnic inequality was only embryonic, while other local health inequalities were better understood. The local equality board is chaired by an NHS CEO and it has ensured new cancer projects have a focus on inequalities in ethnic minority communities – and we heard about improved communication with the community through training the community leaders. A new database is planned to identify cancer patients by ethnic group to aid research and help understand the issues between different communities. We also heard about the recognition of specific cancers which affect the Black, Asian and Minority Ethnic communities, and how funding was available to support community leaders to promote screening programmes.
• In Shropshire, we heard about positive feedback about improved access to care for new remote consultation models for primary care and an ‘attend anywhere’ initiative. Also, ‘Shropdoc’ was providing urgent medical services for patients when their GP surgery was closed, giving access to care pathways and screening services via remote and face-to-face consultations if required.
• In South West London, data collected by the system showed low attendance at breast screening for certain ethnic groups. As a result, the Community Links organisation was tasked by the system to use their diverse group of facilitators to call up patients of the same ethnic background and encourage them to attend screening. They found that more people were attending as a result of this intervention.

Innovation and collaboration in the community

We have heard how services and systems have worked hard to maintain personalised care particularly in community settings. For example, there has been a drive to ensure that people who are immunosuppressed were protected from the Covid-19 virus, and several new ways of working have been developed.

Home chemotherapy has been reported in several systems, alongside the provision of so-called chemo-buses. This involves a team of healthcare professionals visiting people at home to deliver intravenous chemotherapy.

Technology has played a role in helping staff to do their jobs more easily during the pandemic. For example:

• The pharmacy team at the Great Western Hospital in Swindon told us that the pandemic accelerated a move to digitalising the multi-staged process of chemotherapy supply to day unit patients – pre-ordering, chemo screening, bloods checking, and aseptic release – and improved communication between the aseptic unit and cancer pharmacy team. This also allowed home working for some staff undertaking some elements of this process.

One of the challenges during the pandemic was getting used to virtual working. In one system, where face-to-face consultations were deemed necessary, outpatient appointments were relocated to the local hospice to reduce exposure to the virus.

However, digital technologies have also been implemented successfully and in many systems, we heard that multi-disciplinary team meetings are better attended than pre-pandemic. Virtual ward rounds have also been adopted in many NHS trusts, ensuring that patients are reviewed regularly, and management plans are adhered to whilst keeping people safe at home.

Examples of good digital working included:

• use of computer tablets on hospital wards so patients could communicate with their families
• the adoption of virtual consultations to maintain the first appointment for cancer pathways
• use of virtual multi-disciplinary team meetings to ensure collaboration between specialists.

We’ve heard about examples of how systems have focused on allowing people to stay at home or reduce delays in discharge during the pandemic.

A positive example that helped people was in Merton, South London, where patients could send messages to practices without the need for both patient and practice staff to be online at the same time. This helped avoid potential delays and waiting on the phone. A software system called Accurx on the practice computers allows doctors to message patients via email or text and organise video consultations. It can also send an email link which allows relatives to message as well, with patient consent.

Recovery

During the pandemic, one of the major issues that was quickly identified was a backlog in performing diagnostic procedures and surgery. We asked services about how systems are managing this backlog and how they plan to recover their services. We also wanted to hear about examples of collaboration and the way new technology was being used.

• Endoscopy services were badly affected by the pandemic due to the aerosol-generating nature of the procedures performed. However, we heard about innovative new ways of making sure that people had access to such services. For example, there has been greater use of CT colonography and capsule endoscopy for diagnostic purposes. CT colonography is a test that uses CT scans to check the large bowel (colon) and back passage (rectum) non-invasively. Capsule endoscopy on the other hand requires the patient to swallow a pill sized camera which takes pictures as the camera moves through the bowels and sends these to your doctor. These methods are less invasive than regular colonoscopy and allows more people to be investigated in the same timeframe.

We also heard about examples of how local systems and cancer alliances used extra funding to increase booking teams and lists on weekends.

• One primary care service has considered using advanced nurse practitioners to offer more cervical smears to reduce the backlog. Some systems also used private providers and mobile imaging units to increase their working capacity and maintain their service provision requirements during the peak of the pandemic.
• During the pandemic, some providers (such as NHS hospital trusts) have outsourced services (including imaging, treatment and hospital beds) to private companies, but now as we move into the recovery phase, providers are looking to move these services back to the hospital once the backlog in waiting times have been addressed.

We heard about examples of how regional networking and cross-team working has improved.

• In one system, discussions are underway for the implementation of community diagnostic hubs, described as ‘one-stop shops’ where services such as MRI and CT scans can be delivered in the community, away from hospitals to improve access. In another system, chest x-rays are being sent directly to lung consultants, rather than back to GPs – for people who need care, this would streamline the journey between diagnosis and treatment.

We heard about examples of where systems used surgical hubs to maintain surgical services and improve safety.

• In one system, a former reconstructive and burns unit was transformed into a cancer hub - and consequently, there were no more patients awaiting surgery on the priority two waiting list. This which includes patients who need elective surgery or treatment within four weeks to save lives or stop cancer progression.