Improving Equity and Access to Palliative Care Rehabilitation
This weeks blog comes from Mandy Trickett (@MandyHT1) Macmillan Specialist Physiotherapist from NHS Tayside
NHS Tayside – Practice Development Apprenticeship Scheme
In September 2012 I commenced the NHS Tayside ‘Practice Development Apprenticeship Scheme’. This was an opportunity to learn self-improvement, leadership and evidence into practice skills, whilst developing and implementing a practice development idea into a practical reality. The apprenticeship was supported by the Allied Health Professions Directorate in NHS Tayside, led by Dr Jacqui Morris, AHP Research and Practice Development Lead for NHS Tayside. The project was funded by monies from the Chief Health Professions Officer and following a recruitment process 6 AHPs were selected.
We met twice monthly for 6 months and learned about systematic review, evidence synthesis, process mapping, project planning and measurement, and data analysis. The aim was to train us to become practice development leaders in our own clinical areas, and assist others to develop their own ideas in service development.
Rehabilitation in Palliative Care
I am a Macmillan Specialist Physiotherapist and my project has now become embedded in the practice of the multi-disciplinary NHS Specialist Palliative Care Team in which I work.
My project idea began 3 years ago when attending the Scottish Macmillan Cancer Support Conference. I learned of the evidence which exists to support physical activity in the control and prevention of symptoms of cancer survivors, and I asked the question, “so why are we not providing this service?” I went on to complete a literature review of the evidence surrounding physical activity in a palliative care setting, and discovered physical activity not only improves physical performance but can improve quality of life as well. Locally I knew there was an exercise programme already available for COPD patients, but I found many patients with lung cancer had also started to access the exercise class because one of their therapy goals was “to keep active”. This got me thinking about the potential for service development and improved accessibility and so my project developed.
The aim of my project was to reduce inequity and offer evidence based rehabilitative interventions to all patients based on need and not diagnosis. It was important for this service to be offered to all patients who needed it, or wanted it, and the challenge for us as clinicians working with such a diverse group at varying stages of their disease trajectories, was to ensure the intervention was clinically effective, safe and maximised use of NHS resources.
Now, unless individual treatment is necessary, we offer exercise therapy in a group. In this way we can manage a full day’s list of patients in 1 ½ hours with the much added benefit of group therapy and peer support.
Variations in Levels of Knowledge
As the programme developed, it became apparent that the pulmonary and cardiac patients were well-educated in their ability to self-manage their symptoms. However, the cancer patients in general were often fearful of physical activity, deconditioned and frequently reported they had spent the last 2 or 3 years ‘mostly sitting’ as after treatment stopped, these patients continued to need healthcare professional support to help ‘pick up the pieces’ of their lives and move on.
Evidence and Person-centred Approaches
We knew evidence existed to support appropriate exercise therapy in palliative care but what we didn’t know was how best to deliver it based on patient choices and preferences. The apprenticeship scheme offered me the support and direction to ensure that I was gathering the appropriate evidence so that when the project completes in Oct 2013, I will have the evidence which will continue to direct the service. A ‘patient engagement plan’ was crucial during this process and as a result we have informed, engaged with and then consulted the patients who access the service. We provided education sessions to teach patients the benefits of keeping active, set up focus groups with patients and asked what preferences they had for physical activity based on Macmillan Scotland’s recommendation of exercise groups, walking programmes and Chi Gung as suitable forms of physical activity for this patient group. As we developed information leaflets about the services on offer, patients were asked for feedback throughout the process to ensure that what we were providing was what the patients wanted and understood. Many of the patients felt very positive about helping to shape the service for future patients and were genuinely pleased to be involved.
Now, we aim for 100% screening of physical activity levels of all patients referred to the day care unit and advice is offered in line with the Scottish Physical Activity Pathway.
In line with the evidence, our outcome measures show improvement in functional performance and QOL. Almost all patients have expressed an interest in Chi Gung and Macmillan Cancer Support has offered Chi Gung training for staff to provide this on a long-term basis. This will likely be beneficial for the frailer patients to avoid long periods of inactivity.
As patients with life-limiting conditions are living longer with better symptom control, we need to find new ways to offer evidence based interventions to cope with this predicted increase in demand for rehabilitation. An equitable service for all patients who require it should be offered as early as possible in the patient pathway, optimising the ‘teachable moment’ at diagnosis when health behaviour change can be facilitated most readily.
The apprenticeship scheme has turned ‘an idea’ into a sustainable reality now and hopefully long into the future. There has been lots of learning, lots of hard work, and lots of reward through patient benefits; namely maximised functional performance, minimised symptoms and improved quality of life, throughout life.
The Cancer Rehabilitation #Takeover continues next week with a blog from Maureen Thomson, Consultant Radiographer in NHS Greater Glasgow and Clyde