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At the heart of general practice since 1960

How persistence shifted prostate cancer care

Dr Tony Brzezicki on how routine prostate cancer follow-ups were eventually moved into primary care with dramatic results

Dr Tony Brzezicki on how routine prostate cancer follow-ups were eventually moved into primary care with dramatic results

I was involved in working with the hospital trust back in 2004 to develop slick cancer pathways to ensure it met the 31- and 62-day cancer targets.

41230871Being involved in the internal hospital redesign made me question what added value patients got from each hospital attendance. It struck me that follow-up appointments carried out three tasks (at that time):

1 Discuss concerns with the patient
2 Carry out digital rectal examination (DRE)
3 Respond to the latest PSA result.

It was my view that a routine DRE added no advantage to the patient, a view now accepted by NICE. What was left could surely be done in primary care?

In addition, the LHRH agonists were already being given in practices in Croydon. It seemed sensible to try to combine follow-up with the giving of these injections.

Four years on and PBC has allowed us to shift routine prostate cancer follow-ups into primary care through a local enhanced service (LES).

It took 18 months to negotiate and eventually get the green light for the scheme.

But in the first six months of the LES operating, the number of urology outpatient appointments fell by 672 and the new-to-follow-up ratio for practices taking part in the scheme fell by 0.37.

Better for patients

As far as the commissioners were concerned, prostate cancer follow-up involved two outpatient visits annually. However, the burden on patients was much greater. This amounted to:

• two follow-ups at hospital (often with long waits for PSAs to be done)
• four attendances at the practice for their injections
• phlebotomy appointments timed with outpatients
• additional GP visits for non-routine appointments to allay fears, discuss concerns
• GP visits for comorbidities.

It was easy to see there must be a way to make life better for this group, many of whom were elderly and frail.

First steps

My very simple suggestion was for routine follow-up to take place in general practice, where we were used to listening to patients, and could measure and monitor PSA.

A number of meetings with key practices confirmed local GPs felt they could do this task. Later, with the formation of C4, one of the two Croydon PBC groups, this pathway was formally accepted as its first redesign business case. Our local hospital consultant, Mr Gary Das, listened to our proposal and felt it seemed worthwhile developing the idea.

A presentation to Sutton and Merton PCT patient group resulted in strong patient support for the scheme and it has been very well received by patients ever since.

First obstacle

When I tried to work out a rational follow-up protocol for GPs, life became much more complicated. I learned that the current approach to prostate cancer follow-up was anything but simple. Patients were put into groups depending on the cancer stage and type of prostate cancer ranging from ‘watchful waiting', where it had been decided not to treat until necessary, through to palliative care (see box page 26).

Detailed talks with secondary care did identify some groups for whom GP follow-up seemed appropriate (sometimes after an initial follow-up period in the cancer unit).

It wasn't clear precisely which patients these would be but the important point is we agreed there were some patients who could be safely followed up by GPs following discussion with the consultant.

Initially GPs who signed up to the scheme set up prostate cancer registers and identified suitable patients. They then sent the consultant a standard mutually agreed letter asking if the patient was suitable. On receiving approval from the consultant, the patient was sent an agreed letter saying their care could now be done at their practice. This was signed by the consultant and GP. If the patient was happy to have their care shifted, hospital follow-up stopped. Subsequent new patients suitable for transfer of care had primary care follow-up suggested by their consultant.

If a practice does not take part in the scheme, and the consultant asks or states that a patient would be suitable, the practice just lets the consultant know who continues follow-up in secondary care.

Costings

The cost then of a follow-up urology appointment was roughly £75 so the annual cost to the PCT was £150 per patient.

The LES payment, agreed through the LMC, would be £50 per patient per annum, making a potential saving for the PCT of £100 per annum per patient.

Offset against this saving, though, was the cost of the PSA blood tests which were previously included in the tariff for outpatient follow-up plus the risk of new referrals back to the consultant at a cost of £145.

From internal practice audits we felt about 50% of patients could be followed up in primary care. In Croydon the total general practice database from each practice is put on to a central database, the different READ codes are swapped to a common set, and then all the data amalgamated so we can search for information on the total GP-registered patients in Croydon (provided Caldicott rules are met). This database suggested we had 3,000 patients with prostate cancer and that it would be possible to improve the quality of life of some 1,500 patients and save £150,000 for the PCT per annum with £75,000 going into local practices.

Committee junction

At this point the PCT decided to put the project through every committee it had. Each committee raised a series of barriers which had to be overcome. These included:

Ensuring quality in primary care

The clinical governance committee was unsure that clinical quality could be ensured in primary care so we audited the current level of care in secondary care and found 15% of patients lost to follow-up. So secondary care wasn't great to start with! We agreed each practice would keep a register of all patients, and monitor everyone on the register to ensure follow-up was in line with the protocol.

Quality of follow-up protocol

The committee was unsure about the quality of the follow-up protocol. NICE was not due to make recommendations until February 2007, and there were no other similar schemes. Despite the fact the most knowledgeable people locally had developed the protocol, the committee wanted additional assurance that it was safe – but with nowhere else to go for that, the project stalled. It was only by being persistent that this was overcome.

Project not consultant-led

The PCT was unhappy that a project around cancer care was not consultant-led. We set up an email hotline direct to our cancer lead consultant at the Mayday Hospital, paying one consultant session as an SLA (service level agreement) so any GP could obtain an instant opinion on how to proceed when unsure – without having to send the patient back to outpatients (with tariff price tag attached).

The PCT then decided to carry out a ‘risk assessment' to try to establish the project was:

• Safe
• In line with best practice
• Feasible
• Value for money
• In line with wider PCT strategy.

This assessment was continuously delayed, until finally we felt we could not continue with redesign unless the PCT engaged. We had already spent almost 18 months to reach this far. It was only through dogged persistence the PCT finally agreed to get on with the process.

Expert advice from our lead cancer urologist combined with the practice-based commissioners' determination to deliver the project was key. Once approved, it took only two weeks to finalise the project.

Outcomes

In the first six months of the project, the number of urology outpatient appointments fell by 672 or some £50,000. Some 70% of GPs in the PCT attended the training and provided the LES and they saw their hospital follow-ups fall by the anticipated 50%. All practices in the PCT belong to the same PBC group and the expectation is that all practices will take on this work this year.

The 30% who did not had a slight increase in their outpatient follow-up rates.

The next step was to extend the project across the whole South West London Cancer Network. The process was the same, except the urology Tumour Working Group (TWG) designed the new follow-up protocol (which is NICE-compliant). The TWG exists for each speciality for each cancer network as part of the peer review programme and includes representatives from all trusts for a specialty.

It decides how to meet peer review standards, write protocols and so on. So it is the voice for all consultants providing care for a specific tumour – in this case urology.

This is now the official follow-up protocol across the network. Many of the initial barriers to transferring care to GPs were overcome by asking consultants to initiate the process. But sadly no PCT has felt able to trust the risk assessment conducted by Croydon PCT, concluding the model was safe, even though the service has been running for two-and-a-half years now.

Each PCT decided to go through its own approval processes. With so much on the agenda for the NHS, it is difficult to understand why each PCT has to replicate what its neighbour has done – only to adopt the exact same model. In this case, it was even harder to justify this expense and delay when the scheme had been agreed by all sector urologists and supported by the cancer network, which provided its own clinical governance standards. So far three out of five of the South West London Cancer Network PCTs are running the project with the other two due to start soon, meaning coverage of a total population of about 1.5 million.

If PBC is to have an impact, then the process for implementing change needs to be radically overhauled. Despite the Croydon pathway being referred to in Lord Darzi's Healthcare for London report, the SHA has not flagged it up to PCTs as a model that works nor suggested it should be used. Unless we can learn from each other we will fail. PCTs need to trust clinicians and patients when they develop improved pathways and implement them.

Dr Tony Brzezicki is cancer lead, Croydon PCT, and primary care lead for South West London Cancer Network. He is vice-chair of the Pan Croydon PBC Group . With thanks to Mr Gary Das and Professor David Dearnaley, SWLCN

60-second summary Prostate cancer patient categories

Watchful waiting
Conscious decision not to treat until necessary, with no curative intent
Active surveillance
Close monitoring of men who may be cured with radical treatment, should their early cancer show signs of progressing (so avoiding radical treatment in those whose disease does not)
Radical prostatectomy
Surgery for those with early cancers (with curative intent)
Radical radiotherapy
• High-risk localised cancer – stop
• Complications and identify progressions
Brachtherapy
Hormone refractory disease
Palliative care

An audit found 15% of patinets lost to follow-up - secondary care wasn't great to start with

We agreed some patients would be suitable for follow up by GPs, though it wasn't clear which ones

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