Living with and Beyond Cancer (LWBC)

• Living with and Beyond Cancer Team (LWBC)
• Holistic Needs Assessment (HNA)
• Health and Wellbeing (H&W)
• Cancer Care Review (CCR)
• Person centered follow up (PCFU)
• Person centered care interventions (PCCI)
• Gold Standard Frameworks (GSF)
• Somerset Cancer Register (SCR)
• Multi-Disciplinary Team (MDT)
• Rapid Access (RA)
• General Practitioner (GP)
• Clinical Nurse Specialist (CNS)
• Russells Hall Hospital (RHH)
• Referral to Treat (RTT)
• Dudley Group NHS Foundation Trust (DGFT)

Full list of NHS abbreviations

Here at ​The Dudley Group, our patients and staff are at the heart of all we do, to offer a high quality patient experience. We are privileged to have a team of band 4 cancer care navigators within our site specific cancer teams.

Once a patient has been referred on a Rapid Access (RA) pathway for cancer, their care will be coordinated by the team’s cancer navigators and multidisciplinary team (MDT) coordinators. Care coordination is not a one person role, job or responsibility. It’s about joining up services, coordination, providing information and improving communication between care givers, treatment providers and their families, to create a seamless patient experience.

The purpose of this role is to complement the existing MDT and support patients through the diagnostic pathway and treatment pathways, if a cancer is confirmed and follow up.

The cancer care navigator role provides patients and their families who are on these pathways a point of contact f​or support. All patients referred via this pathway will be given an information leaflet explaining the RA process and the cancer care navigator role in their care. Waiting for appointments, investigations and treatments can be stressful for patients. These roles are here to support our patients through this RA process.

If a patient is on a RA pathway and diagnosed with cancer, the cancer care coordinator will be a point of contact for the following:

• To liaise and alert the clinical tea​​m if required.
• To chase scan appointments, coordinate results, appointments and queries related to these aspects.
• Signposting to support services.
• As part of the wider clinical team and MDT to support patients and their families with the elements of a person centred approach to their care.
• Implement the elements of person centred care.
• Complete Holistic Needs Assessment and signposting.
• Treatment summary documentation.

Please contact The Living with and Beyond Cancer team who will allocate your call to the appropriate cancer care navigator:

01384456111 EXTENTION 5315

dgft.lwbcteam@nhs.net

Within six months of your GP practice receiving notification of your cancer diagnosis, you should be invited to have a cancer care review appointment with your GP or a practice nurse. This appointment will give you an opportunity to understand what information and services are available to you in your local area, and to enable you to self-manage your health with support as needed.

Cancer impacts everyone differently and can affect many aspects of life. A lot of people find they need some extra support during and after their treatment. By accessing support this can improve their ability to lead an active and healthy life. Support can be information about treatment and care options, psychological support, advice about financial assistance and support in managing their condition themselves. It is also important support is  extended to families. Carers also play a vital role in supporting people with cancer and it is important that their needs for information, advice and support are addressed.

Addressing all these needs is central to the National Cancer Survivorship Initiative (NCSI), The Macmillan cancer care recovery package and the elements of the Person centred care agenda which is coordinating efforts to improve the quality of services available to people affected by cancer. For more information please refer to:

The Macmillan cancer care recovery package (www.macmillan.org.uk/Recoverypackage)

Extension numbers for our site specific clinical nurses specialists.

A clinical nurse specialist (CNS) is an advanced clinical nurse who can provide expert advice related to specific conditions or treatment pathways, which they have specialised in. They have a wealth of experience, training and knowledge within a specialist area. A CNS will manage patients’ care from diagnostics to treatment and follow up.

Call 01384 456111 and add the following extension numbers:

Cancer Support

Cancer can affect your life in so many ways, Please have a look and some of the support that is available:

Information support:

Do you provide care or support to someone with cancer or Are you a cancer patient looking for support or information?

Come and see us at our new Information Hub which is situated in main reception:

Russells Hall Hospital, main reception, by the volunteer desk and opposite WH Smiths shop.

The Cancer team will be available:

Every Tuesday afternoon 12-1500

No Appointment needed. Just turn up.

If you have a diagnosis of cancer, did you know that you are entitled to free prescriptions?

Patients who are undergoing treatment for cancer, experiencing the effects of cancer or the effects of cancer treatment, and are entitled to NHS treatment, are entitled to free NHS prescriptions via a medical exemption certificate.

If you are over 60, you do not need to apply as you are already exempt from prescription charges.

You can ask for an application form (FP92A) from your GP surgery or oncology clinic. Your doctor must sign it and send it to the address on the application form.

The certificate is valid for five years and covers all NHS prescriptions (whether they are related to your cancer or not).

You do not have to return your certificate before the end of the five years, even if your condition changes.

What is a Holistic Needs Assessment (HNA)?

A HNA is a tool used by healthcare professionals to identify your individual needs and contribute to a discussion about your health. The discussion can then be focused on areas that are important to you, a care plan developed and referrals / signposting made to support services, such as rehabilitation, psychological support and services dealing with the consequences of treatment.

This ensures that your care and support services are planned and accessed appropriately.

Multidisciplinary (MDT) teams and rapid access (RA).

Rapid access (RA) referral pathway was introduced so that a specialist can assess any patient with symptoms that might indicate cancer as quickly as possible. An appointment via telephone, face to face or an investigation is most likely to be offered within 7 days of referral, but within 14 days of referral. GPS diagnose and treat many illnesses, however on occasions they need to arrange for you to be assessed by a hospital doctor who specialises in your problem. This could be for a number of reasons:

• Your GP feels your symptoms or test results require urgent investigation
• Treatment your GP has prescribed has not been effective

Once you have been referred on a RA pathway your care will be coordinated by a team of cancer care navigators.

The role of the Multi-Disciplinary Team (MDT) within cancer care is to meet as a group weekly to discuss each patient utilising all expertise of the specialist practitioners. By working as a team, the different aspects of treatment and services in the best interests of the patient are considered from all specialists and services involved in the patients care. This can then be communicated more clearly with patients and families. The MDT coordinator organises the MDT meeting, tracks cancer referrals and ensures patients are on track, according to the rapid access referral and referral to treat protocols. They are central to the care of cancer patients through the coordination and sharing of data on a wider level.

Below you will see all the site-specific MDTS and the days the meetings are held within Dudley group of hospitals. The cancer care navigators, MDT teams and specialist teams will advise when your case is going to be discussed and what will happen next.

This is a templated letter which is completed by your cancer team and sent to you and your GP after your primary treatment.

The aim of this letter is to provide high quality communication between your hospital team and your GP. The letter will contain details of any treatment you have received, but also useful information about alert symptoms that require referral back to your specialist team, possible consequences of treatment, an ongoing management plan and any required GP actions to help support you. Copies of the completed treatment summary will be sent to you and your GP.