ECN Rehabilitation Board Rehabilitation Needs Assessment

Transcription

1 1 ECN Rehabilitation Board Rehabilitation Needs Assessment (Peer Review Measure 11-1E-114v) Agreement Cover Sheet

2 2 The ECN Rehabilitation Needs Assessment has been agreed by: Position Name Organisation Signed Macmillan AHP Lead; Chair of Rehabilitation Board Kate Patience Essex Cancer Network Date Agreed 18 th September 2012 Position Name Organisation Signed Chair of Essex Cancer Network Board Sheila Bremner NHS Date Agreed 18th September 2012

3 3 Introduction This needs assessment is based on data provided by the NCAT National Rehabilitation Workforce Mapping Exercise of 2011 and the NCAT Cancer Rehabilitation Workforce Model. This mapping exercise captured data about specialist AHPs working in oncology and palliative care, specifically level 3 and 4 as defined in the NICE IOG for Supportive and Palliative Care for adults with cancer (2004). Nonspecialist AHPs and unqualified members of staff (AFC bands 2-4) have a large role to play in all localities but do not form part of this national mapping exercise. The Rehabilitation Workforce Model is predicated upon the interventions indicated within the national rehabilitation care pathways, and does not take into account skill mix (NCAT 2011) meaning that the WTE workforce modelled includes all four levels of competency and intervention from specialist through to patient/carer selfmanagement. The model also assumes that a WTE post will only have 60% of their time dedicated to clinical work which may not be accurate for the ECN workforce which has a high number of band 5-6 who would not be carrying out a large managerial component within their job plan. As the national mapping report and workforce model data cannot be directly compared, this information has been included to guide discussions only, and does not give absolute values required for service development. Current baseline mapping Specialist Level 3 & 4 adult Cancer Rehabilitation posts (Speech and Language Therapists, Physiotherapists, Dietetics, Occupational Therapists and Lymphoedema Practitioners) across Essex have been mapped as part of the Peer Review measures and in accordance with the National Cancer Action Team Workforce Project mapping tool. This data was collected nationally in 2009, and was repeated in The latest full report was released in June 2012 and can be found at In addition to specialist posts, Level 1 practitioners (Bands 2-4) working in local AHP teams were mapped, though have not been included in the final national report. This mapping exercise was completed in November 2011, though some workforce changes have been made locally since this time; these changes have been outlined in the discussion. This report will be presented for discussion within the ECN Rehabilitation Needs Analysis document using the current data, though it must be noted that this will only be accurate at the time of writing this report (August 2012). The Essex Cancer Network serves a population of 1.48 million people. The population in North East and South East Essex has been found to comprise of a higher than average number of elderly people. There are also areas of social depravation in South West Essex and Tendring, and more affluent areas in Chelmsford and Colchester, all of which will impact on cancer incidences. The Essex Cancer Network has four acute trusts: Basildon and Thurrock University Hospital University NHS Trust Southend Hospital University NHS Foundation Trust

4 4 Colchester Hospital University NHS Foundation Trust Mid Essex Hospitals Trust The Essex Cancer Network has two Primary Care Trust clusters: NHS North Essex NHS South Essex There are also four community providers: Anglian Community Enterprise (ACE) South Essex Partnership Trust (SEPT) Central Essex Community Services (CECS) South West Essex Community Services (SWECS) Within Essex Cancer Network there are five adult hospices: St. Luke s Hospice, Basildon Fair Haven Hospice, Southend St. Helena Hospice, Colchester Farleigh Hospice, Chelmsford The J s Hospice (Network wide for people 18-40) In addition there is the Helen Rollason Centre in Chelmsford which provides lymphoedema services. Four levels of service provision for rehabilitation have been identified within the NICE Improving Outcomes Guidance for Supportive and Palliative care for Adults with Cancer (NICE 2004; NCAT 2009): Level 4 Involves advanced practice and expert AHPs who work mostly or exclusively with patients who have cancer (more than 75% of their time). They will provide expert advice and input for clearly defined rehabilitation needs. Practitioners with the skills to provide expert care will have received higher level training (possibly accredited) and as part of their role may provide post graduate training within the specialty. They will be highly experienced senior or consultant practitioners with a defined amount of experience.

5 5 Level 3 Involves experienced, senior AHPs, with higher than basic levels of training in rehabilitation techniques and approaches to managing patients with cancer and/or palliative care needs. They will deliver interventions which require knowledge of the impact of the disease and its treatment. They may have a varied caseload of which 25-75% of their time is focused on cancer and palliative care. Level 2 AHPs who provide treatment at level 2 deliver routine assessments of rehabilitation needs. They will be a graduate in one of the Allied Health Professions. Patients with cancer and palliative care needs form a small percentage of what is often a mixed caseload. Patients may be referred to a more experienced colleague according to need. AHPs working at this level will have a basic understanding of cancer and the impact of the disease and its treatment. Level 1 This involves all people who provide day to day care including the patient and the carer. Patient's needs are assessed using an agreed assessment tool with basic interventions initiated by a healthcare professional. Health care assistants and assistant practitioners working under the guidance of a healthcare professional can also provide care at this level. Referrals may be made to the next appropriate level of care. Because rehabilitation is about the ability to function and perform everyday activities, it is hard to calculate rehabilitation input at this level. ECN Workforce overview Level 3&4 AHP Posts Profession Mapping data Current Data* Workforce Model (WTE) (WTE) Projected No. (WTE) Dietetics SLT OT Physiotherapy Lymphoedema Total *data correct August 2012

6 6 The above table lays out the total number of WTE oncology & palliative care specialist (level 3 & 4) posts by profession in the Essex Cancer Network. The final column also indicates the number of posts required to fulfill the NCAT Rehabilitation Care pathways for the cancer incidence as recorded by ECRIC in Figure 1. Chart to illustrate specialist AHP cancer rehabilitation services available in ECN. MEHT St Andrew's CHUFT SHUFT Dietetics SaLT Physio OT Lymphoedema Acute BTUH CECS ACE Community SEPT SWECS Farleigh Helen Rollason St Helena Hospice/Charity Fair Haven St Luke's J's Level 3/4 post Non-specialist No service available The organisational workforce template above illustrates the presence or absence of specialist post in provider settings across the network.

7 7 The apparent gaps in services are, in some circumstances covered by other agencies, e.g. Farleigh Hospice will refer patients requiring Speech and Language Therapy or Dietetic input to the MEHT or CECS services, and therefore there is a visual but not an actual gap in services. As can be seen, there are level 4 practitioners in many areas to give training and support to team members. This will be looked at in more detail within the Training and Education Strategy (11-1E-116v). The Hospices in South Essex utilise the Macmillan Teams within the local PCT or acute rehabilitation services and do not employ any therapy staff, with the exception on 5 hours of Physiotherapy input at St. Luke s Hospice. The J s hospice does not employ AHP staff. Figure 2 represents the data submitted for the national mapping exercise, and this is the data that was used in the final report. For purposes of accuracy, the most recent figures are used in the discussion of this mapping report. Figure 2: Total of WTE of AHPs in Network per Profession Total Dietician Lymphoedema OT Physio SLT In the 2009 mapping report, ECN had a total number of 24.4 specialist AHP posts. The graphs below (figures 3 & 4) show the difference in these levels from 2009 to 2011.

8 8 Figure 3: Comparison of WTE for AHPs (Level 3) in 2009 compared to Figure 4: Comparison of WTE for AHPs (Level 4) in 2009 compared to The details of the mapping report indicate that based on the population size of 1.48 million served by the Essex Cancer Network the total WTE of specialist cancer rehabilitation posts in 2011 was slightly above the national average. The total number of posts was found to be 33.5 which translates to per million population, the national average being per million, ranging from.31 in North West London (where there is no AHP Lead in post) to in South West London. This is an improvement in WTE posts from the original mapping which took place in 2009, where ECN was found to have a slightly below average number of posts (20.77 per million population with a national average of 21.53). As can be

9 9 seen from these figures, however, the national trend has been a reduction in specialist AHP posts, nationally being reduced by 4%. Although the graphs above depict a reduction in the number of Level 3 posts, it is also shows a clear increase in Level 4 specialist posts. The ECN managed to grow their workforce in this period, demonstrating the raising profile of rehabilitation within the network. Since the mapping exercise, however, the number of posts has fallen for a number of reasons, mainly due to unfilled vacancies or posts becoming generalist due to workforce pressures in times of financial restraint. The current total WTE as of August 2012 stands at 30.99, which translates to per million population, which leaves the ECN still in line with the national average and represents an actual increase of 6.59 WTE posts (27%) despite the financial pressures. Figure 5: WTE of AHPs (Levels 3 & 4) in cancer care by network per 1 million population Network The mapping illustrates a lower than national average number of Specialist Dieticians working within oncology and palliative care in the Essex region. Numbers of Occupational Therapists are higher than the national average, and in fact ECN has the highest number of OTs nationally. It must be noted that many of these OT posts cover community palliative care which is not cancer specific as it also covers all palliative conditions. It is not known from this mapping how much time is allocated to an oncology caseload by each WTE post. Numbers of Speech and Language Therapists, Physiotherapists and Lymphoedema are roughly as the national average. It must be noted that even though posts are demonstrated to be in line with the national average, cancer rehabilitation has historically been understaffed nationally and current levels are not adequate to meet the needs of the ECN site specific rehabilitation care pathways. This is discussed in more depth in the ECN Service Specification and in the discussion section of this document.

10 Mapping Breakdown by Profession Physiotherapy As illustrated in the graph above the numbers of Level 3 & 4 Physiotherapist posts per million population were around the national average, with Essex having 5.54 WTE against a national average of 5.16 (with outlier values removed). Current posts stand at 6.58WTE, which translates as 4.45 per million, which is below the national average. This reduction is due to some senior posts being merged into general roles (such as surgery, respiratory or medical roles), thereby losing their specialist status. Figure 6: Number of Level 3 & 4 Physiotherapists by network per 1 million population Currently, within North Essex there is 1 WTE of Band 6 cover at Essex County Hospital which has been developed into a static role, with 0.5 WTE funding currently from Macmillan for a 2 year project post to expand the Physical Activity Project, which includes the musculoskeletal out-patient service, exercise group and radiotherapy drop in service. The physio also attends the breast cancer Health & Wellbeing Clinic The hospice (St Helena) has a relatively large number of Physiotherapists (1.3 WTE) compared to South Essex Hospices, having a 6 day service currently running. There are currently no specialist community physiotherapy services available from the acute trust or PCT for physiotherapy in the community, but patients are able to access specialist input if referred to the hospice patients must be under the care of the hospice as a whole and are not able to be referred directly to physiotherapy. At Mid Essex Hospital Trust the oncology beds are within a medical ward and are currently covered by Band 7 who also covers other medical wards and therefore has limited time for this client group. St Andrews Burns and Plastics unit has 1.5 WTE Specialist Physiotherapists working with Head and Neck and Breast Reconstruction patients as part of

11 11 their plastics caseload. As these two units work as separate teams they have been considered separately during this mapping process. Again, the number of Physiotherapists within Farleigh Hospice (1.5WTE) is relatively higher than in South Essex and community patients can access this service if appropriate for referral to the Hospice. The hospice physiotherapy team cover a lot of the community respiratory caseload, which is not cancer specific, and this must be taken into account. There are no other specialist community physiotherapy services available within Mid Essex, though general community services are available through CECS. Basildon and Thurrock University Hospital Trust has a limited physiotherapy service on Orsett Ward, which is mainly covered by an assistant managed by the Band 7 of the respiratory team. This Band 7 used to cover the palliative care ward but is an example of workload pressures across a Trust impacting on staff allocation to oncology and palliative care services. St Luke s Hospice employs a Level 4 Physiotherapist for 5 hours per week to cover the in-patient unit and day hospice, though hours are currently flexible (up to per week) demonstrating the need to extend this service. A Case of Need has recently been submitted to Macmillan to expand this service. All community rehabilitation services have generalist posts which mean that there is no specialist physiotherapy available for oncology and palliative care patients in the satellite hospitals or the community. Southend Hospital has a rotational Band 5 covering the oncology and palliative care ward. The physio from the surgical team (level 2) attends the colorectal health & wellbeing clinic.. There is a community service with a named specialist who covers patients with brain tumours and palliative patients in the community, though this service is subject to normal waiting times and has limited capacity for rapid access or ongoing rehab. Fair Haven Hospice has no funded Physiotherapy posts but access Physiotherapy services via the community services provided by Southend Hospital. There is no provision for specialist input in radiotherapy or chemotherapy, and MSK services are provided by the general MSK team. Occupational Therapy The number of specialist Occupational Therapy (OT) posts appears to be higher than the national average within the Essex Cancer Network. The number of Level 3 & 4 posts per million population within Essex is 8.81, with a national average of It must be taken into consideration, however, that the majority of the OT workforce is working within palliative care, not specifically oncology. This is especially evident in Mid Essex, where many of the patients with neurological diagnoses are seen by the hospice team as there is no designated Neuro-rehabilitation within this area, and therefore this mapping would be inaccurate for the population discussed in the mapping report which is cancer specific. In North East Essex, the OT team within CHUFT cover both Essex County Hospital and St. Helena Hospice, as the funding for all of these posts is currently from the acute sector, though notice has been given to the PCT and future funding has not yet been clarified. The Essex County Hospital has 1WTE but this is a Band 6 rotational post at present and is again not considered to be specialist. This person does however work very closely with the OT s at the Hospice and gets specialist training during their year-long rotation. The Hospice OT s work within the community for patients referred via the ECH OT department. The hospice also offers breathlessness and fatigue management groups. ACE have a community team

12 12 covering palliative patients which is based in Clacton Hospital and covers all palliative patients, again not cancer specific. Figure 7: Number of Level 3 & 4 Occupational Therapists by network per 1 million population Mid Essex Hospital Trust currently has 1 WTE rotational Band 6 working on the oncology ward. There is also a static Band 6 OT working within the St Andrew s unit who may have some input with the head & neck or breast patients, though this input is likely to be very limited. The hospice has a team of 1.6 WTE OT s covering the inpatient unit and community palliative patients who are known to the hospice. There is a large OT team working under social services, CECS and the admission avoidance team, but as these are not oncology or palliative care specific they have not been included within this mapping. The referral criteria for OT services at Farleigh Hospice are currently under review, and the general community teams may have a greater role in oncology and palliative care. Basildon Hospital has 1 WTE Band 7 OT working on the palliative care ward. There is a community Macmillan team with 2 WTE Macmillan Funded OT s (band 6 & 7) who cover the community and St Luke s Hospice. There are currently good links between the acute and community teams. The community team provide an equipment provision service only, and other palliative interventions e.g. fatigue management and breathlessness, are covered on the palliative care ward for in-patients but not within the community. Southend Hospital has 1 WTE Specialist OT working on the oncology & palliative care ward and the renal unit. There is a large community team dealing with Long Term Conditions and palliative care consisting of 2.63 WTE OT s. This team also takes referrals for patients at Fair Haven Hospice and are attending GSF meetings at the local GP surgeries to ensure appropriate patients are picked up. This team deals with admission avoidance and equipment provision and is not able to offer palliative services such as breathlessness or fatigue management.

13 13 Speech and Language Therapy The provision of specialist oncology & palliative care SLTs in the mapping report is comparative to the national average for Essex, with 2.5 posts per million population within ECN, compared to a national average of 2.49 posts. There have been changes within the workforce, which now stands at 2.3 WTE in total (1.55 per million pop.). This has been due again to changes in workload moving away from the specialism and unfilled vacancies. Speech and language Therapists play a huge role in the management of patients with head & neck cancer and brain tumours, though have less of a role in some cancers such as breast, urology and gynae. It must be noted, however, that patient with brain metastases may require the services of SLTs. Figure 8: Number of Level 3 & 4 Speech and Language Therapists by network per 1 million population There is currently no dedicated oncology or palliative care Speech and Language Therapy service within North East Essex. Patients are referred from the acute and community sector to the Speech and Language Department within ACE and prioritised accordingly. Patients attending Radiotherapy from Mid Essex, particularly for head & neck cancer, should have access to the speech and language therapy service at ECH. Although a limited service is available there is not a named specialist for these patients, and there is no attendance at the head & neck MDT. Within Mid Essex there are 1.8 WTE Specialist Speech and Language Therapists mainly treating patients with head and neck cancer, as St Andrews is the surgical centre within Essex for this type of surgery. One of these posts is currently filled by a locum. This team covers both acute and community patients, and also takes referrals from Farleigh Hospice when required. The oncology beds are covered by rotational staff, though head & neck cancer patients would be seen by the specialist team as in-patients where possible as they tend to be seen throughout the patient pathway.

14 14 Basildon and Thurrock has 0.5 WTE Speech and Language Therapy posts funded for oncology and palliative care by SWECS, mainly covering patients with head & neck cancer or brain tumours. These patients are followed throughout the patient pathway by this team, who also attend clinics at Southend and Broomfield to follow the patient. Orsett Ward is covered by rotational staff. St Luke s hospice refer to the specialist team when required. Southend Hospital currently has 0.4WTE Speech and Language Therapy post covered by a locum working with Head and Neck patients only. This is, in effect, a WTE post but has not yet been put out to advert. All other oncology would be covered by non-specialist staff, either as in-patients or out-patients. Dietetics The national mapping demonstrates a national average number of Level 3 & 4 posts per million population to be 4.32; within ECN the mapping exercise showed we are below this figure at This has since been further reduced to 5.18 WTE posts (3.5 per million population). Figure 9: Number of Level 3 & 4 Dietitians by network per 1 million population In North East Essex, CHUFT currently has a static band 6 in post at Essex County Hospital covering in-patients and out-patients attending for treatment (for radiotherapy this includes the patients from the Mid Essex region). There is a community Dietetics team which does not have oncology specific posts. Patients from the hospice are referred to the hospital team. Mid Essex has approximately 1.5 WTE staff working with oncology patients, specifically for head & neck cancer services for which MEHT is the regional surgical centre. This team covers the acute and community work along the whole patient pathway. There is also 0.5WTE Band 7 to cover the Upper GI services which are centralised at MEHT. All other tumour sites would be seen by non-specialist teams.

15 15 Basildon currently has a team that cover the oncology caseload (in-patient and community) but there is no specialist oncology service and the patients are therefore seen by general staff. The Palliative care ward is covered by a rotational Band 5. There is currently no funding for the haematology day unit but patients are seen on an as and when basis. Southend Hospital has 1.68 WTE for oncology services with 0.68 band 7 treating head and neck patients and 1 WTE band 6 treating upper GI, lung and gynae patients. The palliative care ward is covered by a rotational post. The referral criteria for the community team covering South Essex has been reviewed and may mean that patients at end of life may not be picked up; this will have an impact on training needs for other community teams e.g. hospice at home or community palliative care teams. Lymphoedema North Essex Lymphoedema Service (NELS) 0.8 WTE lymphoedema practitioner and 0.6WTE Physiotherapy input providing a service for secondary lymphoedema. This service is currently hosted by St Helena Hospice with Macmillan funding. Negotiations are currently under way with the PCT for ongoing funding beyond Mid Essex has 0.8 WTE within the PCT based at St. Peter s, Maldon for a general lymphoedema service, though there has been no information provided regarding the number of cancer patients seen by this team. There is also 1WTE working from the Helen Rollason Centre who have a service level agreement with the PCT to fund this service for patients with cancer. South Essex has 2 WTE nurses working within the team which is part Macmillan funded and PCT funded and cover South Essex. This service is currently hosted by St Luke s Hospice in the short term; future hosting arrangements are not yet clear. All lymphoedema services are for patients with established lymphoedema; there is no provision for preventative roles, other than that supplied by the breast care nurses. Figure : Number of Level 3 & 4 Lymphoedema Therapists by network per 1 million population.

16 As can be seen by figure 11, most posts are within the acute trusts, followed by community teams and hospices respectively. The funding, however, is not necessarily in line with the setting, as some services are provided under SLA from acute services or community providers. For example, the Speech and Language Therapy service at MEHT for head & neck cancer is provided by CECS, and the OT service at St Helena Hospice is provided by CHUFT, and therefore the setting of service provision does not indicate funding source. As can be clearly seen, all of the specialist dietetic input is provided in the acute setting, indicating a need for more input in the community, particularly for patients in the palliative stages of the disease. Figure 11 also indicates that specialist dietetic input is available for head & neck and upper GI cancer, with only one general oncology post. This suggests that there are large gaps in specialist input for most cancer types. Speech and Language Therapy is available in the acute and community settings, as patients are generally followed throughout the whole pathway by the specialist teams. Only head & neck cancer patients are seen by specialist SLTs, which identifies a gap for patients with brain tumours/metastases or other tumour sites who may require specialist input for neurological impairment. Physiotherapy is available in all settings, though much of the community input is provided by hospices, and therefore this service is not available for all patients. Services are mainly held within general oncology or palliative care, although patients across all specialities could benefit from services indicating a gap in service provision and/or training. Occupational therapy is available most commonly in the community, and within palliative care, which demonstrates the importance of OTs in admission avoidance and ensuring quality of life at home, and ensuring preferred place of care can be realised. As palliative care is not oncology specific, this may explain the relatively large number of OTs reported in

17 17 the mapping exercise further work should be carried out to determine the percentage of the caseload that is specifically oncology. Lymphoedema therapists are only found in the community or hospice setting which highlights the need to ensure services are being provided in the acute sector for early intervention and prevention. These services are available for general oncology, as anyone with secondary lymphoedema can access the services. However, the North Essex Lymphoedema Service (NELS) annual report clearly shows the vast majority of patients have breast cancer, with relatively few referrals from urology and gynaecological teams, which indicates educational needs for professionals working within these services. Figure 11: Total WTE of AHPs in Network by work setting SLT Physio OT Lymphoedema Dietician 2 0 acute community hospice

18 18 Figure 12: WTE of AHPs in Network by profession and sub-specialty SLT Physio OT Lymphoedema Dietician 2 0 Breast General Oncology Head and Neck Palliative Care Upper GI Figure 13 outlines the Agenda for Change banding of each specialist post. Most posts are at band 6 (or equivalent as hospices do not use AFC pay scales). Lymphoedema practitioners are at band 5-6, physiotherapists are bands 6-8 (only 1 post at band 8 within head & neck services), occupational therapists are working at bands 6-7. Dietetics are banded 6-8. The highest banding is found within Speech and Language Therapy, with posts in bands 7-8. Figure 13: Total WTE of AHPs in Network by banding and profession Total WTE of AHPs in Network SLT Physio OT Lymphoedema Dietician AFC Banding

19 19 Figure 14: Current WTE of AHPs in Network v recommended WTE from National Workforce Model Sum of WTE Sum of WTE Sum of WTE Sum of WTE Sum of WTE Essex Dietician Lymphoedema OT Physio SLT Figure 14 above indicates the total number of WTE level 3 & 4 posts in oncology & palliative care compared to the numbers indicated by the workforce model developed by the Centre for Workforce Intelligence. The numbers on the left of each pair indicates the current numbers in post in ECN, while the number on the right indicates the numbers required to provide the interventions outlined in the NCAT Rehabilitation Care Pathways. It must be noted, however, that the workforce model indicates the total workforce required (levels 1-4) not just specialists, and for this reason the gap between the two numbers does not imply an absolute gap in posts required but may indicate areas where training and education needs to be put in place to ensure that the generalist workforce is able effectively manage cancer patients where appropriate, while the highly specialist work is carried out by level 3 & 4 staff. This is discussed further in the service development strategy and training and education strategy. Discussion From the above mapping report and information gathered during the gap analysis of the ECN Rehabilitation Pathways it is possible to outline key areas that need to be developed in order to deliver high quality and equitable rehabilitation for people with cancer across the ECN. These key areas have been listed below, some issues being local and others being cross cutting across the network.

20 20 North East Essex Although Colchester is the radiotherapy centre for the North Cluster, there is no specialist oncology/head & neck speech and language therapist as historically this service has not been funded. Patients are seen by the ACE team but not by a named team member, and there is not a SLT representative from the area at the Head & Neck SMDT. The CHUFT Head & Neck CNS has taken on some of the roles normally performed by the SLT team. There is only one dietitian to cover oncology in-patients and out-patients. A large percentage of this caseload is head & neck cancer (for CHUFT and MEHT patients during radiotherapy) and there is, therefore, a limited capacity for other tumour sites. Although there is a specialist physiotherapy service for in-patients and out-patients, the services are available in Colchester only, not in the satellite community hospitals and therefore patients currently have to travel to access services. These services should be available locally, especially in the less affluent areas of the region where travel costs may be a barrier to patients receiving appropriate treatment. There are currently good services available from Occupational therapy for in-patients and in the community. The hospice runs groups in the day services for self-management of symptoms, though non-palliative patients are not able to access such services. There is no specialist provision for out-patient services (i.e. patients undergoing radiotherapy or chemotherapy). The North Essex Lymphoedema Service is currently funded by Macmillan; future commissioning arrangements for beyond the pump primed funding have not yet been finalised. The service has a limited capacity and there are still many patients who are not being diagnosed and treated. With increasing education for clinicians and healthcare professionals the demands on the service are likely to increase and the workforce will need to be reviewed. Mid Essex Mid Essex is the surgical centre for head & neck, breast reconstruction and upper GI cancer and therefore should have an AHP workforce that meets the needs of these clients. As demand for surgery increases the workforce should be reviewed along with the rest of the MDT to ensure that capacity is available to provide a high level of care. There is specialist dietetic input available for head & neck and upper GI cancer, though capacity issues have been raised regarding the upper GI dietetic service provision, as it currently takes up more than the 0.5WTE funded. Other cancer types do not have access to specialist input. The surgical teams have specialist physiotherapists in post to manage the post op care of breast and head & neck patients in the St Andrew s Unit, and a general surgical team in MEHT. As the oncology beds are based on a medical ward and are covered by the medical physiotherapy team, the oncology patients are not necessarily given priority for rehabilitation. There is no access to an exercise programme and there is currently no input into the health and wellbeing clinics or other survivorship initiatives which are being developed within the hospital due to the very limited capacity of the current workforce. The capacity of the

21 21 physiotherapy team within the hospice is also very limited, with very little ability to provide on-going rehabilitation due to the caseload; the referral criteria for these services (and for OT) are at present under review in an attempt to address this. The Occupational Therapy services in Mid Essex again rely on the hospice for community input, and this has caused a very limited capacity for on-going rehabilitation. There is no provision for out-patient services (i.e. patients undergoing radiotherapy or chemotherapy). South East Essex Southend Hospital is the cancer treatment centre for the South of Essex. Despite this there is no specialist physiotherapy service, either for in-patients on the oncology/palliative care wards or for out-patients attending for treatment. There is some community physiotherapy available for assessment in the home but this service is subject to a waiting list and cannot effectively meet the needs of people with a limited prognosis. The team is also not able to provide on-going support and rehabilitation. This also means that specialist physiotherapy palliative care is not provided in this area, leading to inequity across the network. The dietetic service covers head & neck cancer and general oncology and is supported by a dietetic assistant (not included in the national mapping). The head & neck cancer pathway is currently under review, as historically patients from South West Essex have remained under the care of the Southend dietetic team instead of being handed over to the local team. The team are currently working with the CNSs regarding involvement in health & wellbeing clinics. The Occupational Therapy equipment service is available for in-patients and in the community but there is no provision for out-patient services (i.e. patients undergoing radiotherapy or chemotherapy). There are no services available in any setting for specialist palliative care OT (i.e. fatigue or breathlessness management). South West Essex There is no funding for an oncology dietetic service and therefore all patients are seen by a non-specialist team subject to standard waiting times. To ensure that patients receive appropriate care at all stages of the pathway, developments in this service should be considered. The speech and language therapy post covers head & neck cancer as part of a larger caseload which includes palliative conditions such as MND and therefore has a limited capacity. There is no specialist physiotherapy service available for in-patients due to the caseload of the covering team; the ward is generally covered by an assistant. This would not meet the complex rehabilitation needs of patients with MSCC or brain tumours, or complex psychosocial issues. St Luke s Hospice has recognised the need for physiotherapy and are currently in negotiations with Macmillan to fund a project to enable the impact of a local team to be evaluated. This would address some of the inequity in palliative care across South Essex.

22 22 Occupational Therapy services are available for in-patients and patients in the community. There are no fatigue or breathlessness services available in the community but can be provided for in-patients on Orsett Ward. The lymphoedema service is based at St Luke s Hospice, though future commissioning arrangements are not clear. This is the only lymphoedema service available across the south of Essex. MDT/NSSG Attendance Under Cancer Peer Review measures, AHPs are not core members of many MDTs though are listed as extended members of some, e.g. brain, colorectal, breast. Although time is put into job plans for CNSs and clinicians to attend such meetings it has been difficult to obtain agreement from AHP managers to release the time to enable AHPs to participate. Timely intervention from AHPs can have a huge impact on quality of life and patient satisfaction and, therefore, representation of rehabilitation professionals at MDTs should be encouraged. AHP representation at NSSGs has been very difficult to secure in all groups other than Head & Neck due to AHPs not being allowed the time out of their clinical caseload to attend. The ECN AHP Lead currently attends all groups to raise the profile of rehabilitation and highlight any issues. However, this post is time limited and in order to ensure that rehabilitation remains on the agenda AHPs must be able to engage in order to develop services across the network. Specialist Palliative Care In the North and Mid Essex Cluster there are very well established Specialist Palliative Care (SPC) OT and Physiotherapy services, located within the hospices (St Helena Hospice and Farleigh Hospice). However, in the South of the region there are no dedicated SPC rehabilitation services, though there are community OT teams who can manage the equipment provision and admission avoidance. There are no services available for conditions such as fatigue and breathlessness in the South of Essex, leading to large inequalities in the management of people with cancer. Community rehabilitation services can be accessed, though waiting times are often inappropriate for people with a limited prognosis, and general teams do not necessarily have the skills or confidence necessary for dealing with people near to end of life. Data collection In order to demonstrate effectiveness and efficiency of services, data collection is vital. All cancer MDTs have minimum data sets (MDS) which rarely collects information on AHP services. In order to make meaningful changes to services it is vital to capture performance data and outcomes across the network. An MDS for rehabilitation should be developed by the Rehabilitation Board to capture this data across the network to enable analysis. This is also vital in determining capacity and demand for rehabilitation services to enable workforce needs for generalist and specialist teams.

23 23 Cancer Survivorship The National Cancer Survivorship Initiative (NCSI) is working towards improving support given to people living with or beyond cancer using a holistic model of care rather than the traditional medical model. The ECN is working towards the introduction of risk stratified pathways for follow up care for breast, colorectal and urological cancers, though all tumour sites should benefit from the increased support available. As ECN has not historically been involved in any of the pilot sites there are very limited support services currently in place for: Vocational rehabilitation to enable people to remain in work or have the opportunity to retrain for alternative work. Physical activity programmes to enable people with cancer to exercise with confidence which has been shown to improve patient outcomes. Health and wellbeing clinics, giving patients and their families information and advice on side effects of treatment, signs and symptoms of recurrence and how to reaccess the system, support services including support groups, dietary and exercise advice etc. These clinics should be available for people on curative or palliative treatment. Advice about sexuality and resuming/continuing a sexual relationship, which may be an issue covered by OT or Physiotherapy, especially in the palliative care setting. Practical services to help people deal with side effects of treatment and/or cancer, such as fatigue, breathlessness, continence and lymphoedema. This is vital for improving quality of life for a large number of people. By ensuring that survivorship services are available, patients will be more likely to selfmanage their condition leading to greater efficacy and patient satisfaction. Neuro-rehabilitation People with brain and CNS tumours (including Metastatic Spinal Cord Compression) should be able to access rehabilitation dependent on their needs, not on their diagnosis or prognosis. The ECN has produced a neuro-rehabilitation operational policy outlining such services which can be found at There are currently no specialist in-patient neurorehabilitation facilities for this client group within Essex, and patients are not always accepted into specialist neurorehabilitation services on the basis of their diagnosis alone. The number of people affected is not known; this will be audited by the Rehabilitation Board and the brain & CNS NSSG to determine the extent of the problem. Early intervention There are currently few services available to ensure early intervention, other than in the field of head & neck cancer where patients undergoing surgery are routinely seen by a dietitian and speech and language therapist prior to surgery. Patients at risk of complications from any surgery or treatment should have access to specialist intervention in an attempt to prevent the onset of complications. AHPs should be involved in the development and delivery of health and wellbeing clinics for all tumour sites to enable patients to be educated on potential side effects of treatment and

24 24 signpost to support services. This should raise awareness of possible side effects or complications and ensure patients seek treatment early from the correct professionals. For tumour types with a high risk of lymphoedema (breast, urology and gynae in particular), services should be in place to ensure measurements of limb volume are taken prior to surgery to ensure rapid access to services if limb swelling begins to occur to prevent severe complications. Enhanced recovery AHPs play an important role in the Enhanced Recovery Program (ERP), ensuring dietary information, early mobility and early planned discharge are realised. ERP is currently in place for some tumour sites within ECN but it is expected that this will be expanded to include other areas such as urology and gynaecology. Trusts need to ensure that their AHP workforce is able to cope with the demands of expanding services to ensure that ERP is effective. Equipment OT teams are reporting increasing difficulty in accessing certain equipment for people with a short prognosis due to budgetary constraints of the equipment services, and increasing time is spent by OTs clinically reasoning equipment requests, leaving less face to face clinical time for rehabilitation. This situation is currently being audited by the Rehabilitation Board. Communication aids are also problematic, as funding for Alternative & Augmentative Communication (AAC) equipment is not included within the surgical tariff and has historically, therefore, not been routinely offered to all relevant patients due to the lack of stock. This is also the subject of a current audit across the ECN. This is necessary in order to ensure quality of life, social interaction etc. Setting From the workforce mapping it is evident that there are inequities in service provision in different settings across the trust. All of the dietetic input is provided via the acute setting, with little ability to manage people in the community. In contrast, all of the lymphoedema services are provided by community providers and is for complex lymphoedema only, with no input in the acute setting for early intervention. Services should be available for patients at all stages of the patient pathway in the most appropriate setting. This may not necessarily mean an increase in specialist staff to provide services, but may mean more training and education for teams working across settings to ensure that they are able to cope with the needs of patients with cancer. As can be seen from the mapping report, level 3 & 4 professionals are available in most regions for AHP groups; where this is not the case (e.g. Physiotherapy in South East Essex or Speech and Language Therapy in North East Essex), services should be reviewed to ensure that specialist services can be accessed.