A project update from NHS Lanarkshire Dietetic’s Team….
Hi! We are Eve and Alicia, Dietitians from NHS Lanarkshire who have been given the opportunity to improve our services to people with cancer as a result of combined funding from Lanarkshire’s Cancer Strategy and NES (NHS Education Scotland).
As the number of people being diagnosed and treated for cancer increases, Lanarkshire’s Cancer Strategy document (June 2013- June 2016) outlines targets to develop cancer care, focusing on appropriate prevention, screening, diagnosis, treatment, rehabilitation, and support services for the growing population of people living with cancer. Optimal nutrition is a key component at every stage of a person’s cancer journey as it is known to improve outcomes of treatment and quality of life. In this week’s blog, we would like to share the progress on our project thus far, and outline some newly implemented and exciting changes within our department.
The initial aim of our project was to improve the dietetic referral process for people with a cancer diagnosis who are nutritionally compromised (of course, it has since grown arms and legs!). In line with the NHS Scotland Quality Strategy, our service strives to provide a safe, effective and equitable service, ensuring people are provided with person-centred nutritional interventions in the right place at the right time.
Initially, extensive scoping of current service provision was carried out in order to prioritise key areas for improvement. Listening to experiences of other Health Professionals using the service, and gathering evidence from patient surveys resulted in a real understanding of current issues affecting the delivery of treatment.
Across both acute and community dietetic services, almost half of patients surveyed did not fully understand the role of a Dietitian and the reason for their referral. This is no doubt a contributing factor to the high ‘did not attend’ (DNA) rates experienced across the service i.e. 45% non-attendance over a 6-week period in a specialist upper GI cancer clinic. A small audit was subsequently carried out in which patients from this clinic were called to identify reasons for non-attendance. Routine responses included: the stresses of multiple appointments, feeling too unwell to attend in person and again, lack of understanding of a Dietitians role. For this patient population, telephone based reviews at the convenience of the patient, were identified as a significant component of the Dietitian’s workload. As a result of this, over a one-month period, all newly referred patients with an ppper GI cancer diagnosis were given a phone call to offer either telephone assessment or face-to-face clinic appointment (unless otherwise identified as requiring home visit). Routinely all of these patients would have been automatically appointed to out-patient clinic. This test highlighted that for 76% of patients called, an out-patient appointment would not have been the most appropriate method/location of assessment. The likelihood of cancellations/non-attendance by these patients would therefore be increased.
In response to the above, and with the aim of improving patient-experience and access to services, we are taking a more person-centred approach and rolling-out formal telephone clinics for the sample group. All new referrals will also be telephoned by dietetic secretaries and given the option of telephone or face-to-face clinic. In doing so, we hope to reduce out-patient non-attendance and thus improve use of our resources.
In addition to this, patient information leaflets have been developed and these will be posted to patients. The leaflet ‘Introducing Your Dietitian’ explains our role and the benefits of nutritional intervention throughout a cancer experience. We have also identified representatives from across the dietetic service who will help us to build our dietetic website and thus enable better signposting for the public, patients, their families, and other healthcare professionals. It will also highlight further the important role of Dietitians in caring for people with a wide variety of conditions.
There has also been significant quality improvement taking place within the community dietetic department. Cancer care within this department generally falls within the remit of the oral nutritional support service with the majority of assessments taking the form of domiciliary visit. Evaluation of the existing service has identified a lack of standardised triaging of referrals. Instead triaging outcomes are dependant on clinician, workload and locality which clearly impacts upon equity. Feedback from acute dietetic teams and other referring agents such as specialist nurses and GP’s, expressed concern over this; highlighting the possible risks that may arise with a lack of effective prioritisation. To address this, a trial of a telephone triaging system, developed with the community dietetic team, is currently underway in the early stages. This will see Dietetic Assistants using a set telephone pro-forma and scoring system, based on a series of questions regarding weight history, eating patterns and symptoms. It is proposed that this will enable equitable triage of all new referrals within 5 working days of receipt. Patients will then be scheduled for home visits or urgent telephone assessment dependant on clinical need, within the appropriate timeframe. It is hoped that unnecessary home visits will be reduced, reassurance given to patients that referral has been received, and that confidence will be re-instilled in our service for referring agents.
Initial feedback from both staff and patients involved in this test of change has proved promising and further data collection will enable us to evaluate the triaging pro-forma and develop this new pathway.
By May 2016, we aim to have a dietetics service that can rapidly respond to the needs of nutritionally compromised patients with cancer, at any stage of disease. By streamlining the systems currently being trialled and exploring expansion of these to different tumour groups and across sites, we will be improving care and service accessibility, and we will provide more co-ordinated care.
Thanks for reading our blog! We would be grateful for any comments or feedback on our work thus far, particularly if you have experience of similar issues or pathways within your health board. Please feel free to contact us on Eve.McCalmont@Lanarkshire.scot.nhs.uk