Background:

Recruitment and retention of AHP’s in the West and North of Dorset is a real challenge, including the recruitment into AHP registered posts for the cancer workforce. The infrastructure, geography and cost of living are contributing factors.

Various recruitment campaigns have been trialled and failed. So, a review of the registered and non-registered workforce was required.

The AHP strategic workforce project Sept 2021-April 2022 highlighted some of the workforce challenges in West Dorset and provided some suggestions and solutions.

Aims:

To create and embed a career pathway, so from school leavers to ACP/AHP Consultant posts (bands 2-8b)

To embed the concept of social values within the therapies team for both the registered and non-registered staff, to create communities of practice across the Dorset System for the benefits of patients and registered and non-registered staff, in line with the NHS long term workforce plan (2023)

A recommendation of a practice education facilitator post from the strategic workforce project has been employed on a fixed term basis. They introduce a competency framework using the Allied Health Professions’ Support Worker Competency, Education and Career Development Framework. (HEE) and mapping current competencies against it.

Band 2 level: introducing school leavers to the NHS, via traditional A level route, T-levels, BTEC or the trusts scholarship programme. Developing them up to a band 3 level.

Band 3 level: identifying those who would like to progress to registration by

Introducing the level 3 apprenticeship and if they want to move forward to a level 6 apprenticeship.

Band 4 level: looking at the level 5 apprenticeship with the view to developing non registered band 5 positions, particularly with cancer for example breathlessness.

Band 5 level: providing a gold standard preceptorship and rotations around a variety of clinical areas, including acute and community. Offering 5/6 accelerator posts for level 6 apprentice graduates.

Band 6: career conversations, identifying areas of interest or specialism under the four pillars of practice.

Band 7: leadership, ACP and lecturer practitioner, research opportunities to be identified via the appraisal route.

Process:

What did you do?

Liaised closely with stakeholders within the organisation including workforce, education, human resources, AHP’s. Reached out to other organisations within the system including NHS Dorset. Approached schools and colleges to discuss different career routes into AHP professions. Have done various promotions.

Linked in with the ACCEND programme and discussed the personas with various AHP’s including therapies and radiography, with head of education and director of nursing at Dorset County Hospital.

What are the key stages?

Reviewing the various documents AHP support workforce framework, NHS Dorset Clinical Strategy (draft), NHS long term people plan, ACCEND programme. Ensuring that the project is fit for purpose and is appealing to registered and non-registered staff. Ensuring there was engagement at all levels was the key to the success of the project. Updating stakeholders on the progress to ensure their support and that the project was moving in the right direction for the benefit of patients, staff and the trust.

How does it work?

The project is progressing nicely, our support workforce is fully recruited to, and I frequently have people contacting me asking for work.

We have set up a community of practice for occupational therapists (Dorset County Hospital, Dorset Health Care and Dorset Council). The next step will look at different conditions and to develop more rotations, to provide a greater exposure to cancer patients across the pathway, linking back to AHP support workforce framework and the ACCEND personas.

Key Challenge:

This has been a gradual project, managing this way it has been a ‘drip drip’ effect on the workforce, some of the challenges have been that it has been a top-heavy workforce, requiring more from the band 7’s as training needs and additional demands are placed on them.

To develop an ACP (three years of training) there needs to be an ACP post at the end, therefore liaison with workforce and service managers have been key to developing these roles and moving them forwards in business planning.

Impact:

Retention has improved and sickness has dropped (excluding covid).

There is more system working across West Dorset which benefits patients.

The workforce of the future will be more robust and prepared for the increasing demands placed upon them.

Complaints for the first quarter have been less except for orthopaedics.

Next Steps:

• To work closely with our HEI’s developing the level 3, 5, 6, 7 apprenticeships to ensure that the workforce is ready and prepared for future demands.
• To link this model into the PCN’s so that AHP’s and support workers can rotate within GP surgeries.
• Once all the competencies are mapped against the AHP support work framework, a piece of work with the registered staff looking at delegation of patients to allow the support workers to work at the top of their licences and free the registered staff for the more complex patients.
• To develop a community of practice for speech and language therapists. Date set for February 2024

Key tips:

Full engagement of stakeholders.

Be prepared to think differently and take a few controlled risks

Background:

Currently there is not an outpatient therapy service in place for cancer patients at DCHFT, and they don’t have access to prehabilitation prior to active cancer treatment.  There is an ever-increasing evidence base for the need for prehabilitation to improve outcomes. I decided to focus on one particular cancer site due to limited resources, and lung seemed the obvious choice due to the large evidence base with this group of patients, as well as offering scope for education in self-management of breathlessness and fatigue in addition to exercise programme prescription.

Aims

To evidence the need for, and benefits of a having a prehabilitation service for lung cancer patients in West Dorset.  Aim to enter a business case after three month trial.  To be able to share project outcomes with other localities across Wessex

Process:

I researched existing prehab programmes operating in Manchester (prehab4cancer programme) and Southampton.

I met with lung CNSs at DCHFT.  They were very keen to promote prehabilitation with their patients.  We discussed most suitable cohort of patients as those having surgery, likely numbers and patient demographics, as well as lead times for surgery.

Using existing skills of Band 3 therapy assistant (CanRehab trained exercise instructor, and qualified pilates instructor), and Band 6 OT to do joint initial assessments and oversee and support band 3.  Also involvement from oncology SLT if appropriate for hoarse voice, and dietetic advice as required from oncology dietician.

Baseline physical, and quality of life outcome measures will be taken at initial 1:1 session with goals/expectations discussed. Considering usual activity levels, nutrition (offer info and can refer as appropriate), lifestyle factors and psychological support needs (refer on if indicated).

Referrals will come from lung cancer CNSs after their first contact at diagnosis.

Inclusion criteria:  Patients with a recent diagnosis of lung cancer in West Dorset locality, scoring 1-5 on rockwood clinical frailty scale, and identified as suitable candidate for surgery.

Exclusion criteria: cognitive deficits (preventing their understanding/ability to retain information to self-manage their symptoms), progressive comorbidities.

Where?  1:1 sessions (in Robert White Centre clinic room at DCHFT).

Aims of the prehab service:

• To provide an exercise programme which patients can follow at home, giving them tools to help to take control of their well-being and self-manage.
• Their prehab programme will be personalised to the individual, recognising that some patients will need more sessions than others, and will be tailored to their individual needs and goals.
• To optimise patients for treatment physically and psychologically, to improve recovery time, functional outcomes and improve quality of life.

Key Challenges:

Initial challenge relating to suitable space for assessments – limited to 1:1 sessions rather than group work due to limited size of clinic rooms.  No gym space available and limited equipment for programme.

Will update this, when we have started the project.

Impact:

Service will start September 2023-End December 2023 so evaluation of impact has yet to take place.

Next Steps:

The plan was to do a business case after an initial 3 month period to explore scope to continue and extend the service possibly to patients having other treatments (initially those on SABR) and potentially different levels of frailty into the next phase.  Also possible future consideration of prehabilitation for those patients on a palliative pathway.  I aim to produce a clear dataset on the number of referrals seen and time taken for use in business case planning moving forward.  I will evaluate the impact of the programme considering outcome measures, and patient stories.

Key tips:

Don’t reinvent the wheel.  Networking with others who are involved in prehabilitation services and programmes already is hugely beneficial, to identify which baseline/outcome measures they have used and what has worked well with their patients.

It is helpful to utilise and adapt existing resources, with permission

Contact for Further Information:
Name: Sarah Hill
Job Title:  Macmillan OT and, Wessex cancer alliance AHP clinical advisor
Email: sarah.hill@dchft.nhs.uk

Resources:

Baseline assessments to be used: six minute walk test, sit to stand test, EHNA, psychological testing – GAD7 and PHQ-9 and EQ-5D.

Other assessments considered: Functional Assessment of Cancer Therapy -Lung and General (FACT-L and FACT- G), FACIT- F Fatigue scale.

Background:

Cancer incidence across Wessex is higher than the national average at 671 per 100,000(National average 529 per 100,000[1]). In addition to this both Dorset CCG and Hampshire /IOW have significantly more people aged over 65 years than the national average of 17.5% (Dorset 24.4 %, Hampshire 20.2% )[2]

Significant numbers of new cancers are therefore being diagnosed in patients aged 65 and over many of these patients present with a number of risk factors for fraility.

 Head and Neck cancer treatments may involve a combination of modalities including surgery, chemotherapy, radiotherapy and immunotherapy. There is significant risk of functional impairments following treatment and the burden of treatment on older adults who often present with multiple chronic conditions and poly-pharmacy may result in higher levels of treatment toxicity and reduced survival rates[3]. Currently factors such as cognitive impairment, frailty, falls and compromised nutrition are not routinely assessed due to service pressures in any depth in the Head and Neck clinic. Some patients are referred for a Care of the elderly opinion but there are significant delays to this assessment.

The proposed ‘one stop’ CARE assessment bundle provided by a Consultant Care of the Elderly Physician with an interest in perioperative medicine would allow for in depth assessment allowing patients to have more an informed  and optimal management of all these factors so that a comprehensive, personalised ‘CARE’ plan can be developed to optimise age related factors and also identify what patients goal of care is in relation to the cancer diagnosis in the context of their age, co morbidities and quality of life.

Aims:

To embed formal frailty screening and evaluation by a Specialist Consultant in perioperative medicine for older people in to the Head and Neck MDT.(POPs)

To fund a s a pilot project a dedicated POPs Consultant into the weekly MDT discussion and clinic.

For all patients identified with frailty to be seen in a timely coordinated fashion in the Head and Neck clinic by the POPs Consultant for more in-depth assessment.

For all patients with frailty to have time and the opportunity for shared decision making facilitated by the POPs Consultant to develop a person centred package of care relating to their Head and Neck cancer treatment. This may include optimisation before surgery/ Systemic treatment through targeted nutritional input, optimising physical function and medication. To support patients to make an informed decision not to receive active treatment in the context of expected burden of treatment alongside existing frailties.

To provide an opportunity to facilitate the development of better awareness of frailty impact on treatment burden and outcomes through closer MDT working.

Process:

Recruitment of POPS Consultant to attend the weekly Head and Neck MDT meeting  in person to facilitate improved discussion of frailty factors as part a patients work up at the MDT.

Formulation of a Standard operating procedure (SOP) for service to agree referral process, assessment process and outcomes.

Collection of data to record outcomes from POPs assessment including;

Where there was a resulting change in treatment plan

Number Referral on for preoperative assessment

LOS data/readmission and mortality date as a result of POPs intervention, compared with pre development of this service.

Key Challenges:

Significant work force challenge in securing a Consultant with the appropriate skills set to support the clinic.

Securing support from all members of the MDT to engage with the CARE clinic principles.

Ensuring that all patients are appropriately screened for frailty.

Ensuring there is adequate clinic space for the POPs Consultant to work in the Head and Neck clinic.

Securing appropriate administration support.

Ensuring referrals are processed in a timely fashion so that patients do not have multiple hospital visits.

Impact:

It is anticipated that at the completion of the project in approximately 9 months that there will be:

High quality demographic and qualitative data to accurately model the number of older patients presenting with Head and Neck cancer and the extent and degree of their comorbidities.

• More effective MDT discussion around patient suitability for treatment.
• Reduced complications from unrecognised age-related conditions with reduced admission, length of stay and GP appointments and contacts with out of hours services.
• Clearer pathway for pre-optimisation of older patients undergoing head and neck cancer treatment.
• More dedicated time for older patients and their carers to have conversations around their age, frailty and their wishes in terms of cancer treatment. Often the concerns around cancer treatment only become apparent during the treatment itself or are relayed to other healthcare professionals eg CNS, AHPs in a time frame which can impact on the treatment pathway.
• Rapid review of older patients who develop age related complications during their treatment to prevent delays in the treatment pathway.
• Education of wider MDT in all aspects of care of the older person with cancer so that age, frailty and co-morbidities form key aspects of the understanding and development of a personalised package of care and support for all patients.

Next steps:

Current Project Status: On going in first month of POPs Consultant in post.

Support from the Surgical directorate to embed Frailty scoring as mandatory for all patients over 65 with HN Cancer. With all members of the MDT trained to use Rockford frailtyscore and for it to be fully reported on Patients MDT proforma.

To obtain patient feedback on their experience of being able to have more in depth assessment of their frailty and an opportunity to discuss their concerns about proposed treatment burden on their quality of life.

To develop a business case as part of the University Hospitals Transformation of Cancer services to provide on going Pre and perioperative support to Head and Neck cancer patients over 65 who are at increased risk of frailty.

Contact – further info (June Davis)

Background:

Currently it is recognised that there is very limited dedicated AHP Workforce to Acute Oncology Services across Wessex and nationally.

Timely intervention by the AHP workforce including Physiotherapists, Occupational therapists, Dietitians and Speech and Language therapists may reduce the burden of symptoms through risk stratified targeted rehabilitation measures and personalised packages of care and support..

There is little data nationally to establish the rehabilitation and care needs of patients admitted to Acute Oncology Units, whether interventions could be delivered out of hospital and what interventions will prevent readmission.

Aims:

The focus of this proposal is to develop an AHP rehabilitation strategy to support acute oncology admissions across University Hospital Southampton NHS Foundation Trust (UHS) and University Hospital Dorset NHS Foundation Trust (UHD) with the aim of reducing the potential of admission or readmission into the units

This will be achieved through assessment of need for AHP input informed by qualitative and quantitative data collection and to deliver more targeted Cancer AHP rehabilitation to those presenting to Acute Oncology Services (AOS) in both Trusts

Process:

The project will aim to deliver in three phases:

Phase 1 Project set up

Set up of project eg project outline, dissemination of project idea to relevant teams

Recruitment of personnel

Training of personnel

Phase 2  Data Collection 6 months

1. Assessment of the need for AHP intervention and patient rehabilitation by Band 4 allied health support worker using validated screening tools on patients admitted to acute oncology units/hot clinics
2. Identification of assessments found to be clinically valid, timely and appropriate in terms of reducing burden of assessment on patient.
3. Qualitative and quantitative measurement, data capture and impact of this support on service delivery and patient outcome

Phase 3 Completion 3 months:

Focus on the development of a clinical AHP AOS team to deliver personalised package of rehabilitation centred on ‘What Matters to you’. Clear data will be collected to highlight delays and gaps in AHP specialist and non-specialist oncology workforce. Patient outcome measures pre and post intervention and patient feedback will be incorporated in the project design. Collection of case histories is also planned as a powerful tool to illustrate clear examples of improved impact on care.

Findings from project data analysis will be shared with both hospital trusts and Wessex cancer Alliance to inform future workforce planning and business case submissions to develop a more sustainable and equitable specialist and non-specialist AHP oncology workforce to acute hospital trusts.

Key Challenges:

Potential Challenges

1. Securing appropriate work force to deliver project – early identification of staff who have skills within the trust to be offered a secondment role with backfill provided by other part time or bank staff who may benefit from temporary uplift of hours.
2. On-going difficulties with high bed occupancy in trust and delayed discharges preventing admission to AOS. This can be mitigated by good integration with ANP Cancer nurses, CNS and hot clinics to identify patients awaiting or newly admitted.
3. Pressure of existing AHP workforce and inability to deliver care in a timely and optimal fashion- good quality to identify these gaps to develop a further case of need.
4. Adoption of project within the Trust and agreement from multiprofessional AHP management

Impact:

Potential Impact

With improved data on rehabilitation needs of patients admitted to AOS appropriate plans can be delivered to secure optimal work force to address these needs.

Provision of timely AHP intervention to AOS will reduce admission and readmission rates, length of stay free up capacity within the acute pathway.

Improved patient satisfaction through engagement in them in terms of what is important to them in terms of functional rehabilitation and support to optimise their functional and quality of life as far as possible.

To develop a clear and visionary rehabilitation strategy for Acute Oncology Services across Wessex that is patient Centred, high quality and evidence based and supports the strategic cancer objectives for Wessex.

Next Steps

Current Project Status:

Create multiprofessional Band 4 Job description to allow for panel matching.

Recruitment into the project

Future Work

• Use the results of this project to create a robust and sustainable AHP outline for AOS units across Wessex and be integral to the development of services
• Development of Personalised Care and rehabilitation package to support the patient across the rest of their cancer pathway including onward referral to community services and consideration of End-of-Life care and support plans in a timelier fashion for frail patients or those with comorbidities.

Contact for Further Information:
Name: Lynsey Clode  Lead Oncology Dietitian/Penny Scott Clinical Lead Speech and Language Therapist
Email: lynsey.clode@uhs.nhs.uk

Background:

Research evidences[1] that early palliative care input has a positive impact on patient outcomes. In Portsmouth, patients in receipt of a palliative diagnosis do not always access palliative services, despite signposting to early support available. Barriers to service access include a view that palliative services only support patients in the last days of life, reduced awareness of service provision and late referrals.

We set out to develop a service, reaching patients who do not access current services, to reduce the stigma of accessing palliative care and provide nursing and therapeutic input at an earlier stage to improve outcomes.

Aim:

To expand our existing Clinic resource in a community out-patient setting, providing specialist palliative nursing and Allied Health Professional intervention to patients with an anticipated prognosis of over 12 months, potentially from the point of palliative diagnosis.

To encourage referrals (including self-referrals) for patients who may not have been identified for traditional palliative services, reducing any barriers preventing access to service provision.

To provide proactive, person-centred support through holistic specialist assessment, advanced care planning, symptom management and onward signposting, working collaboratively with other organisations to optimise patient outcomes, maximise quality of life and support self-management, reducing the burden on primary/secondary care.

Process:

A scoping exercise was completed to better understand how the current specialist palliative care offer fits alongside the broader end of life offer in Portsmouth, what barriers exist to service access, how and when referrals are made, gaps in service provision and the skill mix available. We looked at research findings and similar service provision; comparable out-patient services are currently based in secondary care.

We were granted Macmillan funding in January 2023 to pilot the clinic for 2 years with 0.5 WTE Band 6 Clinical Nurse Specialist and 0.5 WTE Band 6 Specialist Allied Health Professional. Once recruited, the postholders developed the service set up, promoting the service widely and developing relationships in primary and secondary care, community and the voluntary sector. Referral pathways, outcomes and evaluation plans were agreed.

Patient referrals or self-referrals were accepted from May 2023.

The current process following referral is:

• During triage, patients are telephoned to establish acuity, patient need and suitability for the service. If patient’s needs warrant intervention from the community Specialist Palliative Care team, referrals are transferred to the team.
• Patients are assessed in their preferred clinic location by the most appropriate professional, using the Integrated Palliative Care Outcome Scale (IPOS), a patient reported outcome measure, to identify their most pertinent issues. A personalised care plan is devised, and patients are supported with interventions for symptom management, advance care planning, psychological support or signposting to other relevant services according to their needs.
• If required, patients are offered follow-up appointments by the relevant professional.
• At the point of discharge, patients are offered open access back into the service. Referral and service quality data are captured using SystmOne; baseline and outcome IPOS scores and a patient experience survey are completed for evaluation purposes.

We will use the period of grant funding to evidence the impact of the clinic to build the case for investment from our local CCG.

Key Challenges:

Recruitment for both posts as fixed term contract positions was challenging in this current climate, delaying the start of the project.

Referrals to the service were slow to build as a new service set up. The types of patients referred have been variable, impacted in part by the interpretation of “early” palliative patients. Some patients have had inappropriate expectations of the purpose of the clinic appointment, despite contact with patients before their appointment to explain the remit of the service. Many of the patients referred have multiple complex needs and some patients seen have been much nearer the end of life than the clinic criteria. We acknowledge that prognostication can be very challenging in palliative care and a patient’s condition can change quickly. We have been able to flex our service provision to ensure a patient’s needs are met where possible or seamlessly pass the patient onto the community team’s caseload where the urgency or complexity cannot be held within the clinic.

We have continued to dedicate time to service promotion and relationship building with potential referrers, to reach the most appropriate patients for the service, however wide service promotion is time consuming.

Impact:

We are in the early stages of data collection; we are currently exploring the data quality from the initial system set up and considering how best to comprehensively measure the full impact of the clinic.

Within the first 5 months, 25 patients have been referred into the clinic and only 1 has been an inappropriate referral. 48% of referrals received have been from secondary care, 40% have been from primary care / community and 12% have been self-referrals.

Anecdotally the clinical demand has been predominantly for symptom management support, as other developments have arisen, for example in primary care, through the introduction of care co-ordinator roles where future planning is now more routinely explored.

It has not been possible to re-measure patient reported outcomes for every patient, as a small number have deteriorated, requiring referral to the community specialist palliative care caseload and 3 patients have died.

We have received some positive feedback from patients regarding the support they have received from the clinic, such as:

“I felt it made a big difference and was grateful to talk to the CNS”.

“It was a relief to be able to share our thoughts and experiences with a third-party professional”.

“I felt so supported by the clinic team. They were wonderful”. 

Next Steps:

Current plans include further engagement with our partners in secondary care, primary care networks across Portsmouth city and the community therapy teams in Portsmouth, to encourage referrals for suitable early palliative patients.

We will continue to review our outcome measures and work with our system partners to ensure we are demonstrating the impact on the health and care economy, in order to develop a business case for sustained investment in earlier interventions.

We are grateful to Macmillan for funding this pilot and for giving us the opportunity to test new ways of working, building the case for the benefits of earlier palliative intervention and broadening the reach the clinic provision to include AHP support.

Key tips

• New service provision takes time to become established and sufficient time needs to be factored in to continue to promote the service in an ongoing capacity.
• Comprehensive scoping locally, regionally and nationally prior to the service set up was invaluable. The findings were instrumental in directing the focus of the project and service design.

Contact for Further Information:
Solent Specialist Palliative Care Team
Name: Olivia Birch
Job Title: Macmillan Physiotherapy Team Lead
Email: olivia.birch@solent.nhs.uk

[1] https://www.nice.org.uk/guidance/ng14  NICE 2019 Evidence review of End-of-life care for adult’s service delivery