SECTION B THE SERVICES

Transcription

1 SECTION B THE SERVICES 2012/13 NHS STANDARD CONTRACT- SECTION B THE SERVICES (Amended 14 February 2012)

2 SECTION B PART 1 - SERVICE SPECIFICATIONS Service Specification No. 1.2 Service Commissioner Lead Provider Lead Period Date of Review Anglia Cancer Network Head and Neck Cancer (including ENT and Oral/Maxillofacial) Rehabilitation Service Specification As for localities within the Anglia cancer Network region As for localities within the Anglia cancer Network region Annually from date of issue 1. Population Needs 1.1 Overview and Context Cancer rehabilitation services are provided by a multidisciplinary team of cancer specialist, generalist and community health professionals, social care professionals, support workers, patients themselves, and their carers. Five main Allied Health Professional (AHP) groups are recognised as providing the basis for rehabilitation within cancer care: physiotherapy, occupational therapy (OT), speech and language therapy (SLT), dietetics and lymphoedema therapy. Head and neck cancer and its ensuing treatment can result in severe debility and dysfunction in terms of nutrition, speech and communication, post surgical management of stoma, body image and psychosocial issues, physical difficulties in movement of the head, neck and shoulders, swelling and lymphoedema, dental problems and fatigue (NICE 2004). The complexity and severity of the disease and its treatment can have a devastating impact on both the patient and their carers. The provision of appropriate specialist rehabilitation services are paramount in ensuring patient safety and welfare, and in providing the rehabilitative treatment, support and advice required by this patient group, enabling them to manage and move forward though diagnosis and treatment stages, into survivorship and beyond. Anglia Cancer Network is a geographically large Network and covers a population of 2,671,020 (ONS 2010). It spans six primary care trusts (See Table 1): Table 1 Primary Care Trust Population Norfolk 765,100 Suffolk 602,000 Cambridgeshire 616,300 Bedfordshire (shared Network coverage with 416,000 (299,520 within AngCN) Mount Vernon Cancer Network) Gt Yarmouth and Waveney 214,700 Peterborough 173,400 The annual incidence of head and neck cancer in 2008 for the Anglia Cancer Network region was 494 (UKCIS). 2012/13 NHS STANDARD CONTRACT- B1

3 In 2009 a centralisation of head and neck surgical services was undertaken with two centres established: Cambridge University Hospitals NHS Foundation Trust (CUHFT) in the west of the Anglia geographical region and Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH) in the east of the region. This centralisation has influenced the head and neck patient referral flows for supportive and rehabilitative services, (See Table 2): Table 2 CUHFT NNUH Main Site Referrals From Peterborough City Hospital (all H&N patients) West Suffolk Hospital (ENT patients) Queen Elizabeth Hospital Kings Lynn (MaxFac patients) Bedford Hospital (some oncology referrals) Hinchingbrooke Hospital (all patients) Papworth Hospital (all patients) Local area (all patients) Ipswich Hospital (all surgical patients) Queen Elizabeth Hospital Kings Lynn (ENT and some MaxFac patients) James Paget Hospital Gt Yarmouth (all patients) Local area (all patients) Ipswich Hospital Peterborough City Hospital Local area (ENT patients) Local area (MaxFac patients) West Suffolk Hospital (MaxFac patients) Local area (ENT and some H&N) Out of region referrals (dependant on funding) It should be noted that Bedfordshire will not be commissioning from the specification at this time, as the pathways and model of care are primarily directed within the Mount Vernon Cancer Network region, although rehabilitation services are offered within both network areas. Data regarding provision of rehabilitation services in the Anglia region of Bedfordshire are included in the specification for informational purposes. Using the national baseline mapping definition of specialist cancer/palliative care posts (NCAT 2009/11), there are specialist head and neck rehabilitation practitioners in Anglia within speech and language therapy, dietetics and physiotherapy disciplines (See Figure 1). This reflects the recognised specialist requirement in oncology arising from the particular complexities of head and neck patients and the prevalence of nutritional and speech/communication/swallowing issues within this population. Physiotherapy, OT and lymphoedema therapy practitioners will often see head and neck patients as part of a wider population encompassing many tumour groups. 2012/13 NHS STANDARD CONTRACT- B2

4 Figure 1 WTE Specialist Posts in Head and Neck Cancer by Locality and Profession Physio Dietitian SLT Cambs Norfolk Suffolk Beds (excluding Luton/S.Beds.) GTYW Peterborough There is significant variability of specialist head and neck rehabilitation workforce provision between localities within the Network and this may be weighted by locality population to give a useful comparative view. (See Figure 2). Figure 2 WTE Specialist Posts in Head and Neck Cancer (all identified professions) per 100,000 population of locality Cambs Norfolk Suffolk Beds (excluding Luton/S.Beds.) GTYW Peterborough It may be seen from this that there is currently no AHP specialist posts for head and neck cancer in the Gt Yarmouth & Waveney or Peterborough areas. A specialist SLT post has been agreed and is waiting to be established in Peterborough, and will work across Peterborough and Cambridge localities. Consideration of the site of specialist posts within localities reveals that in each case specialists are based at acute centres (CUHFT, NNUH, Ipswich Hospital and Bedford Hospital). This geographical provision of specialist posts potentially contributes to inequity of service delivery and accessibility issues, and places an unsustainable burden upon specialist services both in terms of capacity issues (with increasing patient referrals to specialist centres) and also the necessity for specialists to 2012/13 NHS STANDARD CONTRACT- B3

5 provide support and advice to other rehabilitation practitioners in managing complex patient needs. It should be noted that successful bid was made in September 2011 for funding for specialist head and neck SLT provision at Peterborough City Hospital, but the post is yet to be established. The 2004 Improving Outcomes Guidance for Head and Neck Cancer (NICE 2004) made recommendations for the structure of services and the provision of Local Support Teams (LST). Included in this was the calculation of the number of rehabilitation professionals required to provide supportive and rehabilitative services within a Network population of 1.5 million people. The requirement for IOG compliance, measured via peer review, is one of the main drivers in cancer services, and this provides the appropriate baseline when identifying need within this specification. In addition, the national rehabilitation care pathway for head and neck cancer has been utilised alongside cancer incidence, to develop a national workforce model of recommended whole time equivalent (WTE) workforce in each of the five main cancer rehabilitation allied health professions Commissioners and providers must take into consideration the figures within the national model as indicative of best practice workforce provision. However to initiate the process, and in recognition of the current transitional environment of the NHS and financial constraints, this specification recommends IOG level compliance in the first instance, identifying enhancements required to deliver services via the hub and spoke model, with the phased, longer term intention to enhance services to the levels recommended within the national model once new commissioning structures are in place. 1.2 Evidence base Document NICE (2004) Guidance on Cancer Services: Improving Outcomes in Head and Neck Cancer Key Points Establishment of Local Support Teams (LST) for every cancer centre or unit that manages patients with head and neck cancer Provision of skilled care, locally, throughout the network. Written rehabilitation plan for every patient, prior to discharge, drawn up by MDT members, with the patient, carers and identified member of the LST Advice and education to patients and carers on self management valves/stomas, and of wound, mouth and dental care. Provision of contact number to patient of member of LST. Specialist expertise in head and neck required in terms of speech and language therapy and dietetics. Speech and Language Therapists, Dietitians and a variety of other therapists are required from the pretreatment assessment period until rehabilitation is complete DoH (2007) Cancer Reform Strategy Provision of services to improve the lives of those effected by cancer Customised/individualised advice, care and support Enablement of self-management 2012/13 NHS STANDARD CONTRACT- B4

6 DoH (2008) End of Life Care Strategy Provision of services to improve the lives of those effected by cancer Customised/individualised advice, care and support Enablement of self-management DoH (2008) Operating Framework NCAT (2009 and 2011) Supporting and Improving Commissioning of Cancer Rehabilitation Services: - Guidelines - Reviews of Evidence NCAT (2010) Rehabilitation Care Pathway for Head and Neck NCAT (2011) Cancer Rehabilitation Workforce Model Access to AHP s will improve health outcomes and reduce health inequalities Review of workforce mix and deployment of AHP s to support improvements in accessibility and experience of services The role of rehabilitation to support patients with cancer and palliative care needs. Quality Rehabilitation Service Evidence base for cancer rehabilitation Intervention and symptom based care pathway for rehabilitation services for head and neck cancer patients Creation of estimated workforce requirements to support cancer patients 2. Scope 2.1 Aim To develop and provide a high quality, accessible, equitable and fully integrated cancer rehabilitation service for head and neck patients throughout the Anglia Cancer Network area by: Developing and enhancing service levels and resources Utilising a hub and spoke model. Rehabilitative interventions based upon need and with delivery opportunities closer to home Improved integration, and education, training and support provision between cancer specialist practitioners, and generalist and community practitioners. 2.2 Recommendations and Key Points Recommendations: i) That a hub and spoke configuration is adopted for the Anglia Cancer Network head and neck cancer rehabilitation services. (pb10) ii) That a phased approach may appropriately be considered by commissioners and providers, commencing with Option 1 as an immediate commissioning priority, before moving to the service redesign required for Option 2. Option 3 proposes a direction of travel for future commissioning and represents the accomplishment of gold standard service provision. (pb13) 2012/13 NHS STANDARD CONTRACT- B5

7 Key Points: i) The Head and Neck Rehabilitation Service for the Anglia Cancer Network will be led by head and neck cancer specialist AHP practitioners, with appropriate clinical and medical support, providing and supporting centre and outreach services. (pb7) ii) iii) iv) Rehabilitation teams will be comprised of cancer specialist, generalist and community practitioners, and will be guided by NICE Improving Outcomes Guidance - Local Support Team (LST) recommendations to provide high quality, flexible, locally-based, seamless care for head and neck patients throughout the Network. Generalist and community practitioners will be supervised and supported by specialist practitioners. (pb7) A written rehabilitation plan for every patient, prior to discharge, drawn up by MDT members, with the patient, carers and identified member of the LST. (pb8) IOG provides that SLT and dietitians must be specialists in head and neck cancer, and physiotherapists and OT s must have an interest in and experience of working with this patient group. (pb8) v) Commissioners and providers must demonstrate that they have placed sufficient resources within physiotherapy, OT and lymphoedema therapy to ensure that those needs of this patient population are met within the remit of this specification.(pb9) vi) vii) viii) ix) Four hub locations are identified at CUHFT, NNUH, Ipswich Hospital Trust and Peterborough City Hospital. (pb11) Spoke locations are proposed at James Paget University Hospitals NHS Foundation Trust in Gt Yarmouth and Waveney, Queen Elizabeth Hospital Kings Lynn NHS Trust, Hinchingbrooke Health Care NHS Trust and also most notably at Cromer Hospital. (pb11) Commissioners and providers must establish appropriate referral lines between hubs and spokes, which may encompass cross-locality working. (pb11) Specialist services provided on an outreach basis must be provided in conjunction with clinician support. It may be appropriate to offer less complex services in locations where clinicians are not present, but this should be provided on the basis of at least a in SLT or dietetics, and appropriate policies and lone worker support and procedures should be in place. (pb12) x) All specialist practitioners must have training, educational, service development and support components built into their work plans. (pb14) xi) xii) xiii) Commissioners and providers are encouraged to seek innovative approaches to service provision and funding, recognising the current provision of outreach services and developing joint funding and cross boundary commissioning patterns. It is suggested that smaller localities may wish to consider a joined-up approach by part-funding the additional posts allocated to their locality, but which may more effectively be based and employed by larger centres which already manage head and neck services in these smaller localities, and who will provide outreach services locally.(pb14) Commissioners and providers should demonstrate that implementation of the Anglia Cancer Network Rehabilitation Care Pathway is established, or undertake to adopt the indications as part of service delivery to this patient group. (pb14) Agreement is sought from commissioners and providers in respect of the waiting time guidelines at Section 3.2. (pb16) 2012/13 NHS STANDARD CONTRACT- B6

8 2.3 Objectives Establish a hub and spoke model, enhancing and building upon existing services and developing new services as required. Develop service provision through workforce enhancements commensurate with the proposed model, and evidence base. To ensure provision of Local Support Teams to manage the aftercare and rehabilitation of patients (NICE 2004), working across acute, community and social service settings. Provide patient-centred care with access to and provision of specialist support and advice for patients regardless of care setting. Education, training and clinical mentorship of generalist and community practitioners by cancer specialist practitioners to ensure maintenance of skills at a local level. Ensure equity of access to services including equipment provision across the Anglia Cancer Network area. Provision of written rehabilitation plan, enhanced discharge care provision, and reduction of delays in discharge and co-ordinated care following discharge. Provision of high quality, supported services closer to home. To improve patient outcomes and experience. 2.4 Service Description In relation to head and neck cancer rehabilitation services it is recognised nationally that particular expertise and specialism is required for speech and language therapy and dietetics, and these professions form part of the core multi-disciplinary team treating this patient group. Other rehabilitation practitioners (OT, physiotherapy) are identified as extended members of the multi-disciplinary team and are expected to have an interest in head and neck cancer and experience of managing this patient group. (NICE 2004). In addition to these 4 rehabilitation groups, the need for lymphoedema management services may be overlooked, and the prevalence of lymphoedema in head and neck cancer is underestimated, with evidence suggesting some form of secondary lymphoedema is experienced in up to 75% of head and neck cancer patients post treatment with surgery and radiotherapy (Deng et.al. 2001). Consideration must also be given to the length of time that rehabilitation services may be required for head and neck patients, with sustained input from point of diagnosis and prophylactic intervention and advice, through treatment stages and the increasing development of survivorship management, through to end of life and palliative support. A specific example is the case of laryngectomy patients whom are routinely followed up by speech and language therapists for life. The Head and Neck Rehabilitation Service for the Anglia Cancer Network will comprise a hub and spoke model and will be led by head and neck cancer specialist AHP practitioners, with appropriate clinical and medical support, providing and supporting centre and outreach services. Rehabilitation teams will be comprised of cancer specialist, generalist and community practitioners, and will be guided by IOG LST recommendations to provide high quality, flexible, locally-based, seamless care for head and neck patients throughout the Network. Generalist and community practitioners will be supervised and supported by specialist practitioners. 2.5 Service Model The proposed model of rehabilitation services for head and neck cancer within the Anglia Cancer Network region utilises a hub and spoke approach, building upon existing services and resources, developing novel service sites, and seeking to implement and disseminate good practice. It is also driven by the desire to provide excellence of care closer to home and improve patient experience and care, whilst recognising the need to provide effective and efficient services. The resource implications for the service model are drawn from the IOG and National Rehabilitation Workforce Model (NCAT 2011). 2012/13 NHS STANDARD CONTRACT- B7

9 2.5.1 Improving Outcomes Guidance (NICE 2004) This guidance was issued in 2004 and is clear regarding the requirement of rehabilitation services and the investment that must take place in order to provide such services. Particular requirements involve the provision of LST by every cancer centre or unit, with access to the expertise to manage the rehabilitation needs of all its patients, working with centres and primary care. SLT and dietitians must be specialists in head and neck cancer, and physiotherapists and OT s must have an interest in and experience of working with this patient group. Inherent in the IOG is the need for close liaison between community and specialist practitioners to ensure patient needs are met. This includes a written rehabilitation plan for every patient, prior to discharge, drawn up by MDT members, with the patient, carers and identified member of the LST The LST and the MDT are separate entities, although practitioners may be members of both or either teams. The IOG estimates that each Network of approximately 1.5 million population will require an additional 5.3 WTE SLT and an additional 4.7 WTE dietitians to provide adequate rehabilitation and support services (NICE 2004). In consideration of the population of the Anglia Cancer Network of million, this would equate to an additional 9.4 WTE SLT and an additional 8.4 WTE dietitians. Table 3 provides the current WTE specialists posts in head and neck in SLT and dietetics within Anglia. Table 3 Current WTE Specialist Posts for SLT and Dietetics in Head and Neck Cancer by Locality Cambs Norfolk Suffolk Gt Yarmouth & Waveney Peterborough SLT 1.6* * Dietetics *(Please note there is recently acquired funding for 0.8 WTE head and neck specialist SLT post at Peterborough. A further 0.2 WTE funding is being provided by CUHFT for the post, to provide services primarily at Peterborough, but also with sessions at CUHFT). The IOG notes that the number of professionals already in post was not known at the time of publication, although shortfall in workforce was clear. Therefore this paper has taken into consideration current workforce provision and has taken a conservative position that the IOG guidance intent is to take into account resources already in post. Table 4 demonstrates the additional workforce requirements for SLT and dietitians if the recommendations within the IOG are transposed across the localities within the region taking into account population weighting and current provision: 2012/13 NHS STANDARD CONTRACT- B8

10 Table 4 IOG recommended additional WTE Specialist Posts for SLT and Dietetics in Head and Neck Cancer by Locality, less current specialist provision. SLT 0.6 (note new sessions) Gt Yarmouth & Peterborough Waveney (once new post established) Cambs Norfolk Suffolk Dietetics Cancer centres currently may manage specialist head and neck rehabilitation services both at their own centres and by provision of services and staff to other locality areas i.e. NNUH provides specialist rehabilitation services for head neck patients within Great Yarmouth and Waveney as well as Norfolk. Commissioners and providers must take such referral patterns and workload into consideration when assessing commissioning needs, and joined-up approaches to proposals within this specification will be required. The IOG does not make specific recommendations in relation to additional resource provision for physiotherapy, OT or lymphoedema services. However, Physiotherapists and OT practitioners working within general oncology support the needs of these patients, and generalist practitioners within these professions undertake essential and required services to ensure appropriate supportive and rehabilitative care is provided within a variety of settings. There remains a need to identify and develop the generalist workforce in localities who are managing such patients and whom will need the support, training and clinical supervision provided by more specialist practitioners to ensure high quality and safe service provision regardless of the setting. Commissioners and providers must demonstrate that they have placed sufficient resources within physiotherapy, OT and lymphoedema therapy to ensure that those needs of this patient population are met. It is of note that Service User input and case studies have indicated particularly that the provision of physiotherapy services for head and neck patients may not be timely nor appropriately accessible to meet needs National Workforce Model The National Workforce Model, published in May 2011, provides the estimated workforce specification for a rehabilitation service, based upon cancer incidence, the entire patient pathway from pre-diagnosis to end of life, and nine main tumour groups, including head and neck ( It should be noted that the patient catchment areas for some localities do not always match the incidence specific to the resident population within that locality i.e Peterborough SLT also serves populations within Cambridgeshire and Lincolnshire (not currently funded for Lincs.), and Bedfordshire populations and services are split between Anglia Cancer Network and Mount Vernon Cancer Network. Commissioners and providers will need to take into account specific locality factors when applying the recommendations and proposals within this specification. Usefully the model is predicated upon 4 levels of rehabilitation practitioner from patient self-management and unregistered practitioners, through generalists, to specialist expert practitioners. Commissioners and providers may therefore use such modelling to assess their current service provision for this patient group and also to provide assurance and an evidence base for increasing resources where need is identified. B9 2012/13 NHS STANDARD CONTRACT-

11 See Appendix 1 for Anglia Cancer Network and locality rehabilitation workforce resource modelling. Table 5 identifies the modelled workforce estimates for rehabilitation services required for the head and neck cancer incidence in each locality within Anglia. Table 5 Indicative National Workforce Model WTE Workforce Requirements per Locality and Profession Cambs (Incidence 96) Norfolk (Incidence 167) Suffolk (Incidence 111) Gt Yarmouth & Waveney (Incidence 48) Physio OT Lymphoedema SLT Dietetics Peterborough (Incidence 32) Evidence Summary Robust workforce provision in rehabilitation is required for appropriate and high quality service provision. It is clear at this time that current service capacity and resources are insufficient in light of this evidence base and that consideration must be given to the increasing cancer incidence year on year, and to issues of succession planning and service structure. It is therefore recommended that a hub and spoke configuration is adopted for the Anglia Cancer Network head and neck cancer rehabilitation services Hub and Spoke This configuration may be identified as offering: Hub Recognised head and neck centres; case management, complex rehabilitative interventions; one stop multi-disciplinary clinics alongside active treatment; provision of outreach services; out of hours advice and specialist support available; provision of supervision, education, training, support and practice development for generalist practitioners. Spoke Location for outreach clinics led by specialists. Less complex rehabilitative interventions; less specialist rehabilitative provision; local clinics; active, integrated cross-referral pathways with Hubs; local clinic; supports community and domiciliary rehabilitation and patient self management programmes. Figure 3 demonstrates the proposed locations for each aspect of the model: 2012/13 NHS STANDARD CONTRACT- B10

12 Figure 3 Map of Head and Neck Rehabilitation Service Locations Hub Spoke Cromer Hospital Hubs Four hub locations are proposed at CUHFT, NNUH, Ipswich Hospital Trust and Peterborough City Hospital. These locations recognise the main sites for head and neck patient services including the two regional surgical centres for head and neck. They also acknowledge the strongest rehabilitation referral pathways and the current provision (or proposed provision in the case of Peterborough) of rehabilitation specialist posts. Specialist posts and services must be provided from hub locations. Geographical coverage and access distances were also considered. Service development and specialist provision at Peterborough would be required before hub status could be confirmed. These four hubs will provide specialist, complex, multidisciplinary interventions and form the resource for outreach clinics, clinical support and education/training required by the generalist workforce in the providing the service needs of this patient group. Patients local to Papworth Hospital are seen within services at CUHFT. Spokes Spoke locations are proposed at James Paget University Hospitals NHS Foundation Trust in Gt Yarmouth and Waveney, Queen Elizabeth Hospital Kings Lynn NHS Trust, Hinchingbrooke Health Care NHS Trust and also most notably at Cromer Hospital. Commissioners and providers must establish appropriate referral lines between hubs and spokes, which may encompass cross-locality working. 2012/13 NHS STANDARD CONTRACT- B11

13 Head and Neck Rehabilitation Specialists from the hub locations will provide services for the outreach clinics in conjunction with general oncology specialist rehabilitation practitioners and generalist practitioners. Spokes will also provide the base for local community services for patients who are able to self-manage with appropriate support. Specialist services provided on an outreach basis must be provided in conjunction with clinician support. It may be appropriate to offer less complex services in locations where clinicians are not present, but this should be provided on the basis of at least a in SLT or dietetics, and appropriate policies and lone worker support and procedures should be in place. Specialist practitioners in head and neck cancer will also provide appropriate clinical supervision, service development, education, support and advice to other rehabilitation practitioners as part of the service provision at spoke sites. A specific case is made for development of novel service provision for this patient group at Cromer Hospital. Cromer is ideally placed to provide appropriate geographical coverage for the area of North Norfolk which is otherwise wholly unresourced for this patient group. Consideration must also be given to the otherwise excessive distances that patients must travel to access services. Provision of an outreach clinic at the facilities provided within the Cromer Hospital site staffed by specialist practitioners from NNUH would establish excellence of care closer to home for patients and enable practice development for generalist staff. Bedfordshire Bedfordshire is divided between and served by Anglia and Mount Vernon Cancer Networks. Within Anglia, Bedford Hospital has specialist head and neck dietetics provision. SLT specialist head and neck services are offered at Luton and Dunstable Hospital within the Mount Vernon Cancer Network, and provide a limited amount of support to the local SLT teams serving Bedford Hospital and north/mid Bedfordshire. There is currently no specialist head and neck SLT provision for Bedford Hospital or north/mid Bedfordshire. SLT services are being considered by the Bedford locality to ensure improved access to patients at Bedford Hospital and in north/mid Bedfordshire (excluding Luton). Table 6 details current head and neck rehabilitation specialist provision and the IOG recommended additional provision for the Anglia Cancer Network population figures within Bedfordshire. Table 6. IOG Recommended additional provision for Anglia Cancer Network population within Bedfordshire Current WTE Specialist Head and Neck Cancer Posts SLT Dietetics Service Provision and Development IOG Recommended Additional WTE Specialist Head and Neck Cancer Posts Specialist head and neck practitioner posts in SLT and dietetics currently exist in CUHFT, NNUH and Ipswich Hospitals, and funding is in place at Peterborough City Hospital for SLT. Recognising the requirement for head and neck specialism in SLT and dietetics within the IOG, outreach clinics provided at the spokes must be staffed by specialist practitioners in these fields, and for more complex intervention, supported by clinicians. Commissioners and providers must therefore consider resource implications required to provide an outreach service and the necessary increase in WTE for practitioners and provision of administrative and support staff that this will entail. Physiotherapy and OT oncology specialists may appropriately engage with generalist and community service provision to provide advice, support and clinical supervision and leadership. This will also require B /13 NHS STANDARD CONTRACT-

14 additional resources. 2012/13 NHS STANDARD CONTRACT IOG guidance regarding interest in and experience of head and neck cancer within physiotherapy and OT practice must be taken into consideration to ensure a high quality service. There is a chronic shortage of lymphoedema services across the region, and current provision is at or close to capacity. It is therefore essential that further resources are considered by commissioners and providers to ensure that this unmet need in the head and neck cancer patient population is not overlooked. The frequency of spoke outreach clinics has been determined by consideration of patient need and capacity of current services and the existing experience of practitioners providing such services. Such session times indicate clinical provision and do not take account of necessary travel to outreach locations, which would need to be added to the service provision. See Table 7. Table 7 - Frequency of Spoke Outreach Clinics Profession SLT Dietetics Physiotherapy OT Lymphoedema Frequency of Outreach Clinic 2 sessions per week 1 session per week 1 session per month 1 session per month 1 session per month 1 session = half day Options Three options may be considered in light of the above: 1. IOG indicators only (SLT/dietetics) 2. IOG indicators, with implementation of Hub and Spoke model (SLT/dietetics). 3. IOG indicators (SLT/dietetics), with implementation of Hub and Spoke model for full rehabilitation MDT (SLT/dietetics/physio/OT/lymphoedema therapy) and taking national workforce modelling into consideration. It is proposed that a phased approach may appropriately be considered by commissioners and providers, commencing with Option 1 as an immediate commissioning priority, before moving to the service redesign required for Option 2. Option 3 proposes a direction of travel for future commissioning and represents the accomplishment of gold standard service provision. It should be noted that Options 1 and 2 would not permit improvement in current physiotherapy, OT or lymphoedema services for this patient group. On the basis of the above outreach frequency for each profession and the IOG and modelled indicators for rehabilitation workforce requirements, as well as expert opinion from specialist practitioners, and current workforce, the following additional resources are advised: Option 1: IOG indicators for rehabilitation workforce requirements (SLT/dietetics). (WTE and Band) Cambs. Norfolk Suffolk GTYW Peterborough SLT 0.6 Dietetics (0.8 funded provision meets IOG) Band 8a ( funded) /13 NHS STANDARD CONTRACT- B13

15 Option 2: IOG indicators, with implementation of Hub and Spoke model (SLT/dietetics). (WTE and Band). Cambs. Norfolk Suffolk GTYW Peterborough SLT 1.4 Dietetics Band 8a 0.6 Option 3: IOG indicators (SLT/dietetics) with Hub and Spoke implementation for full rehabilitation MDT, taking into consideration National Workforce Model. (WTE and Band). Cambs. Norfolk Suffolk GTYW Peterborough SLT 3.0 Dietetics 1.5 Physiotherapy 1.0 OT 0.5 Lymphoedema 1.0 Therapy Band 6/7 1.0 Band 8a Commissioners and providers are encouraged to seek innovative approaches to service provision and funding, recognising the current provision of outreach services and developing joint funding and cross boundary commissioning patterns. It is suggested that smaller localities may wish to consider a joined-up approach by part-funding the additional posts allocated to their locality, but which may more effectively be based and employed by larger centres which already manage head and neck services in these smaller localities, and who will provide outreach services locally. In addition to the above, commissioners must ensure that appropriate administrative support is available, and consideration should be given to the resourcing of unregistered healthcare practitioners with appropriate competencies, to support service provision and provide suitable skills mix and effective working procedures. Appropriate equipment and working environments must be established at locations where head and neck services do not currently exist and where outreach clinics will be developed. All specialist practitioners must have training, educational, service development and support components built into their work plans, as this will be essential to ensure high quality service provision and will facilitate the development and support and supervision of community based and generalist practitioners based at spoke locations. 2.6 Care Pathway The Anglia Cancer Network Rehabilitation Care Pathway, developed in conjunction with the Anglia Cancer Network Rehabilitation Steering Group, and agreed by the Network AHP Lead and Network Site Specific Group for Head and Neck may be found at Such pathway will form the basis for referral, triage and management of patients within the service specification. Commissioners and providers should demonstrate that implementation of this pathway is established, or undertake to adopt the indications as part of service delivery to this patient group. 2012/13 NHS STANDARD CONTRACT- B14

16 2.7 Accessibility/acceptability Head and neck, oral, ENT and maxillofacial patients will be able to access the service via: MDT referral Specialist oncology team Consultant/key worker Specialist, generalist or community AHP/health care professional GP/Primary care services Self-referral via one of the above. On receipt of referral, services will make an appointment for assessment and ongoing management/intervention as required. Services will be provided in a variety of settings including acute centres (hubs), outreach or community settings (spoke), or domiciliary settings, based upon clinical need and service/resource availability. Patients with a diagnosis of head and neck or ENT cancer, residing within the Anglia Cancer Network area, or outwith the area but residing in a location whereby their usual referral pathway for oncology services will be to head and neck services within the Anglia region, and requiring rehabilitation interventions, may be referred to the rehabilitation services via routes outlined at Section 2.2 Referrals for children and young persons with head and neck cancer will require joint management in consultation with relevant paediatric practitioners. Referral systems will differ between localities but in all cases providers must demonstrate that referral is timely, proactive, and based upon the assessed needs of the patient. Once a patient has been in receipt of rehabilitation services and has moved into supported selfmanagement, provision must be made by providers to facilitate patient-led referral back into services for assessment and ongoing management. 2.8 Interdependencies The Head and Neck Rehabilitation Service for the Anglia Cancer Network Region will require agreement and joined up working practices and relationships amongst a number of groups and key stakeholders: Acute and community trusts and services Hospices and specialist palliative care providers Commissioners Providers Network Site Specific Group for Head and Neck Cancer Patient User Groups Anglia Cancer Network Mount Vernon Cancer Network Healthcare practitioners and professionals Voluntary and charitable organisations GP/primary care/ccg 2.9 Equity of access to services This document complies with the Suffolk PCT Equality and Diversity statement. An EqIA assessment is available on request to Anglia Cancer Network Programme Quality Manager, Gibson Centre, Exning Road, Newmarket CB8 7JG 2012/13 NHS STANDARD CONTRACT- B15

17 3. Applicable Service Standards 3.1 Hours of operation Hours of operation will be dependent upon the nature of the service and clinical and holistic needs of the patient population. Providers must outline the hours of service provision for each rehabilitative service offered and how they will provide out of hours support, advice and guidance to patients and carers, how they will meet the needs of enhanced recovery programmes within the acute setting, and their policy on emergency admissions if relevant. 3.2 Response time and prioritisation Referrals will be triaged by an AHP practitioner, with appropriate liaison with clinicians as required. Delivery of care will be based foremost upon patient need, taking into consideration capacity and service provision. Guidelines for appropriate standards are as follows: In-patient referrals should take place within 2 working days of receipt. Urgent out-patient and community referrals should take place within 1 week. Routine referrals should take place within 4 weeks. The above must be subject prioritisation based on clinical need, and the use of appropriate chronological list management systems. For equipment provision: Urgent requests should be met within 2 working days Routine requests within 7 days Specialist equipment access times to be agreed on an individual basis. For patients requiring discharge at End of Life, or for prevention of inappropriate emergency admission at End of Life, equipment must be accessible within 4 hours of need being identified. Agreement is sought from commissioners and providers in respect of these waiting time guidelines, and once agreed, commissioners and providers must ensure that contractual arrangements, resources and service setting are appropriate to facilitate such standards. 3.3 Referral Processes and Sources Please see Section 2.7 for accessibility. The Anglia Cancer Network Rehabilitation Care Pathway for Head and Neck indicates referral criteria and triggers, and must be implemented by providers and individuals referring to services. ( 3.4 Discharge criteria and planning In terms of transfer of care from specialist to generalist services and prior to discharge from the acute services, providers must ensure that a written rehabilitation plan is produced, and agreed by the referring practitioner, the referee practitioner and the patient and carer. This must include information and advice to the patient/carer in relation to on-going management and appropriate re-access to specialist services. The provision of a hub and spoke model will facilitate the appropriate step-down process towards eventual discharge, ensuring that patients have access to treatments, care, support and advice based upon their clinical and holistic needs. 2012/13 NHS STANDARD CONTRACT- B16

18 Once patients rehabilitative conditions have appropriately stabilised, there should be a movement towards discharge from services, towards supported self-management. Rehabilitative services should be provided for as long as clinical need and patient benefit requires. This will include provision for life-long rehabilitative intervention and needs of laryngectomees. 3.5 Self care and Service user/ carer information Service providers should encourage movement towards supported self-management in order to provide patients with a measure of control over their own conditions, maximise and optimise service capacity and scope and support benefits realisation of shortening hospital stays and preventing readmissions. Self-care is also the ultimate expression of care closer to home. All patients and carers should be provided with appropriate information regarding their condition, and potential signs and symptoms that may indicate a need to re-enter services for active intervention, as well as guidance and advice on supported and subsequently stand-alone self management. Patients and providers should be encouraged to access information via the Information Prescriptions portal rehabilitation pathway, to ensure that all information is current and evidence-based: ( 4. Key Service Outcomes 4.1 Expected Outcomes Compliance with rehabilitation aspects of IOG for Head and Neck Cancer Compliance with peer review measures on the provision of Local Support Teams Delivery of an evidence-based, quality service via implementation of the locally agreed Anglia Cancer Network rehabilitation care pathway for head and neck cancer. Improved engagement and integration of cancer specialist, generalist and community rehabilitation practitioners. Establishment of clear education, training and support for generalist practitioners and community teams in the care of head and neck cancer patients. Reduction in length of hospital stays (bed days) Reduction of unnecessary hospital re-admissions Reduction in number of emergency admissions Greater efficiency in acute hospital out-patient clinic appointments Development of agreed waiting times and access to equipment to improve responsiveness of and accessibility to services. Delivery of rehabilitation plan on discharge with clear goals and measureable outcomes utilising validated tools. Contribution to the QIPP agenda There is a current lack of metrics within cancer rehabilitation, but relevant KPI s may include: Number and reason for re-admissions/emergency admission Number of referrals to hubs and spokes Proportion of patients receiving rehabilitation plan within discharge planning process. Proportion of patients receiving services within agreed waiting/equipment access times. Patient satisfaction/experience measured by surveys Peer review compliance on local support team provision Complaint analysis Quality of life measurement during patient pathway following rehabilitation interventions Audits of implementation of rehabilitation care pathways. Audit of feeding-related or communication difficulties Audit of provision of nutritional assessment at key stages in patient pathway 2012/13 NHS STANDARD CONTRACT- B17

19 Improvement in patient outcomes measured via validated tools in speech and language therapy, dietetics and physiotherapy. Benchmarking based upon appropriate patient reported outcome measures 4.2 Quality and performance standards The Anglia Cancer Network, in conjunction with commissioners, providers, the Rehabilitation Steering Group and patient users, will identify appropriate core data information sets, measures and outcomes to enable audits and surveys of service provision, effectiveness and productivity and satisfaction scores from both patients and health professionals. Guidance from national groups indicates the use of the rehabilitation pathways as a basis for identifying appropriate measures, and these will be developed and utilised in the process of this service development. This service specification will appropriately contribute to the QIPP agenda in ensuring the provision of a quality service, encouraging innovation in practice and provision, demonstrating productivity through benefits realisation of reduced hospital stays, prevention of re-admission and reduced prescription costs, and ultimately in supporting a proactive service that defines prevention as one of the main aspects of rehabilitation Location of Provider Premises Please see sections 1.1 for geographical overview and section 2.5 for service model location details. 6. Appendices 2012/13 NHS STANDARD CONTRACT- B18

20 Appendix /13 NHS STANDARD CONTRACT National Model of Workforce Requirements Anglia Cancer Network Summary report from AHP Cancer Rehab workforce tool Patient information used in calculation: Incidence for ACN = 494 AHP workforce required from calculation / (Full Time Equivalent) Speech and Language Therapists Total 26.0 Dietitians Total 14.1 Physiotherapists Total 4.3 Occupational Therapists Total 3.1 Lymphoedema Therapists Total by professional group, showing break down by pathway stages Pal & EoL Survivorship Treatment Diagnosis Pre Diagnosis Diet Lymph OT Physio SaLT 2012/13 NHS STANDARD CONTRACT- B19

21 Norfolk Summary report from AHP Cancer Rehab workforce tool Patient information used in calculation Cancer site Brain Breast Colorectal Gynaecology HeadNeck Lung UpperGIHBP UpperGIOG Urology Incidence AHP workforce required from calculation / (Full Time Equivalent) Physiotherapists Total 1.5 Occupational Therapists Total 1.0 Dietitians Total 4.8 Speech and Language Therapists Total 8.8 Lymphoedema Therapists Total by professional group, showing break down by pathway stages Pal & EoL Survivorship Treatment Diagnosis Pre Diagnosis Diet Lymph OT Physio SaLT 2012/13 NHS STANDARD CONTRACT- B20

22 Suffolk Summary report from AHP Cancer Rehab workforce tool Patient information used in calculation Cancer site Brain Breast Colorectal Gynaecology HeadNeck Lung UpperGIHBP UpperGIOG Urology Incidence AHP workforce required from calculation / (Full Time Equivalent) Physiotherapists Total 1.0 Occupational Therapists Total 0.7 Dietitians Total 3.2 Speech and Language Therapists Total 5.8 Lymphoedema Therapists Total by professional group, showing break down by pathway stages Pal & EoL Survivorship Treatment Diagnosis Pre Diagnosis Diet Lymph OT Physio SaLT 2012/13 NHS STANDARD CONTRACT- B21

23 Cambridgeshire 2012/13 NHS STANDARD CONTRACT Summary report from AHP Cancer Rehab workforce tool Patient information used in calculation Cancer site Brain Breast Colorectal Gynaecology HeadNeck Lung UpperGIHBP UpperGIOG Urology Incidence AHP workforce required from calculation / (Full Time Equivalent) Physiotherapists Total 0.8 Occupational Therapists Total 0.6 Dietitians Total 2.7 Speech and Language Therapists Total 5.0 Lymphoedema Therapists Total by professional group, showing break down by pathway stages Pal & EoL Survivorship Treatment Diagnosis Pre Diagnosis Diet Lymph OT Physio SaLT 2012/13 NHS STANDARD CONTRACT- B22

24 Peterborough Summary report from AHP Cancer Rehab workforce tool Patient information used in calculation Cancer site Brain Breast Colorectal Gynaecology HeadNeck Lung UpperGIHBP UpperGIOG Urology Incidence AHP workforce required from calculation / (Full Time Equivalent) Physiotherapists Total 0.3 Occupational Therapists Total 0.2 Dietitians Total 0.9 Speech and Language Therapists Total 1.7 Lymphoedema Therapists Total by professional group, showing break down by pathway stages Pal & EoL Survivorship Treatment Diagnosis Pre Diagnosis Diet Lymph OT Physio SaLT 2012/13 NHS STANDARD CONTRACT- B23

25 Gt Yarmouth & Waveney Summary report from AHP Cancer Rehab workforce tool Patient information used in calculation Cancer site Brain Breast Colorectal Gynaecology HeadNeck Lung UpperGIHBP UpperGIOG Urology Incidence AHP workforce required from calculation / (Full Time Equivalent) Physiotherapists Total 0.4 Occupational Therapists Total 0.3 Dietitians Total 1.4 Speech and Language Therapists Total 2.5 Lymphoedema Therapists Total by professional group, showing break down by pathway stages Pal & EoL Survivorship Treatment Diagnosis Pre Diagnosis Diet Lymph OT Physio SaLT 2012/13 NHS STANDARD CONTRACT- B24