Lincolnshire is a rural county, with a population of around 800,000. It has one of the largest numbers of people with skin cancer in the East Midlands. The diagnosis and management of people with suspected cancer had become increasingly challenging for two main reasons. One was the difficulty in providing capacity for the year-on-year increase in the number of suspected skin cancer two week wait referrals without impacting on access to care for people with other skin problems, such as psoriasis and eczema. The second issue was a lack of any specialist nursing support for patients diagnosed with skin cancer. This was highlighted by the Getting It Right First Time (GIRFT) review in 2018, and by the East Midlands Cancer Alliance in 2019. Innovative community and hospital clinics were developed to address these challenges. These Spot and Rapid Access clinics focused on the initial review of people with suspected skin cancer, providing a more efficient service to patients with suspicious skin lesions. Alongside the clinics, a new model of care was introduced to support patients diagnosed with skin cancer. This Skin-XL project incorporated a mix of site-based skin cancer support nurses, specialist skin cancer nurses and nurse surgeons.
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Discussions with the local commissioners and primary care clinicians resulted in a process for the establishment of the community Spot clinics. The locations of the service and staffing were agreed with the primary care teams. Referral pathways, booking arrangements and documentation were agreed within the stakeholder group. The service was implemented and modified as necessary in the community settings. This community clinic model was then replicated to deliver the Rapid Access clinics in the secondary care setting. Data were collected and reviewed regularly, and used to flex capacity and demand, particularly for skin surgery services. Community sites were set up in Louth and Lincoln, with Rapid Access clinics established in the United Lincolnshire Hospitals NHS Trust hospital sites in Boston and Lincoln. The Skin XL project began with a Project Initiation Document, for stakeholder engagement and comment. External funding was secured from local partners, including the Lincolnshire CCG, East Midlands Cancer Alliance and Health Education East Midlands. Next, three cancer support nurses (one based at each main site) were seconded from their outpatient posts for one day a week in June 2019. They undertook bespoke training and set up a helpline to give patients support immediately. Two trainee nurse surgeons were appointed in September 2019, who successfully completed skin surgery training by September 2020. Two skin cancer clinical nurse specialists were appointed in the spring of 2020 to support the delivery of cancer follow-up clinics. An administrator was recruited in June 2020 to support the clinical nurse specialist (CNS) clinics and triage the helpline, ensuring that the nursing staff could maximise patient-facing duties. An Excel spreadsheet was used to document all patient interactions for data analysis, and patient experience surveys were collected throughout the project.
The results of the community Spot clinics were evaluated and published as part of the Elective Care Development Collaborative 100 Day Challenge, where teams developed and tested innovation in delivering elective care in 100 days. The pilot data showed that only seven of the 73 patients were referred to the 2WW pathway when, previously, all 73 patients would have been. The model was well suited to delivering close-to-home care, particularly for the elderly, frail population of people with skin cancer. It was likely to be one of the new models proposed to deliver skin cancer diagnostic services in the post COVID-19 recovery plan. The nurse-led clinic skin cancer and surgery lists enabled consultants’ time to be focused on new cancer referrals and non-cancer patients. The CNS follow-up clinics saw 32 patients per week, with plans to increase this number to 48. The nurse surgery service comprised two surgery lists, seeing 12 patients a week. This was set to double to four lists per week (24 patients). Surgical support was also provided to the one-stop clinics by the nurse surgeons, releasing doctors to see more patients and reducing delays.
Sustainability and Spread
A business case has been developed for permanent funding of the skin cancer nursing service, which will be integrated into the wider dermatology service. The project has been well received by the executive board of the Trust, along with senior management within the division of medicine. There are no perceived risks to the integration of the Cancer Support Service within the department, as the team is made up of nursing staff recruited from the dermatology team, who have existing relationships. Although the service has been separately funded, it has run alongside the dermatology service, ensuring regular communication and joint working. The learning from these initiatives has been shared nationally. The community Spot clinic model is influencing the development of the post-COVID-19 2WW referral optimisation pathway being developed by the NHS Cancer team, NHS England and NHS Improvement National Outpatient Transformation Programme (NOTP).
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