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SCHEDULE 2 - THE SERVICESService SpecificationService Specification No. ServicePrimary care stratified follow-up of stable prostate cancer patientsCommissioner LeadNorth Central London SPG Provider LeadGeneral Practice Period2017/2018Date of ReviewMarch 2018Version Version 10The aim of this service is to provide enhanced support for prostate cancer patients in the community including annual holistic needs assessments (HNAs) and PSA monitoring, which will also encourage and facilitate the transition of care of prostate cancer patients stable on treatment out of the acute hospital setting and into primary care. This supports the strategic objectives of improving patient experience, moving care closer to home and delivery of productivity savings. This will provide patients with a more holistic approach to their care, closer to their own homes.GPs who have signed up to the Locally Commissioned Service will be required to provide this service as set out in section 3 of this service specification.An annual year of care payment of ?50 per patient who meets the criteria, who is coded with READ codes H8gg2 and 389h and are being managed in line with the requirements as set out in this service specification. This new Locally Commissioned service has been developed with the support and agreement with London Cancer Urology Board and acute trusts including UCLH, Royal Free Hospital, Whittington Hospital, North Middlesex Hospital. Systems will be in place to facilitate the smooth transfer of suitable patients to primary care practices in Barnet, Enfield, Haringey, Islington and Camden follow-up. Patients will be transferred following secondary care assessment for suitability and accompanied by Treatment Summaries that include patient-specific protocol for PSA monitoring, any consequences of treatment (medical, physical and psychosocial) and instructions for onward management.1. Population NeedsNational/local context and evidence baseIn the UK, the numbers of men living with a diagnosis of prostate cancer will continue to increase as the population ages. The traditional follow up model follows a standard regime of hospital outpatient appointments and surveillance tests over several years. Increasing incidence of cancer (currently 3% per year) alongside increased survival rates are putting huge pressure on outpatient resources and impacting on the quality and efficiency of services provided. The ten year survival for prostate cancer is 83.8% and recurrence is usually detected through PSA monitoring which can be conducted in a primary care setting. The challenge of providing effective aftercare for this increasing number of men is a driver to redesign care pathways away from traditional consultant led models of follow up. Both patients and professionals have identified that many appointments are unnecessary, add no value and incur unnecessary costs for patients and the NHS. As 70% of cancer patients have at least one other long term condition there are potential advantages in establishing a primary care led model of care which is fully integrated with the care of other long term conditions.To improve patient experience and outcomes, this specification has been written in line with The National Institute of Clinical Excellence (Prostate cancer: diagnosis and management CG: 175) with input from local expert Urology specialists and supported by the London Cancer Urology Board. The primary care stratified pathway described within this specification has been tested in Croydon CCG. The evaluation of the pathway showed that patients were in favour of primary care follow-up with feedback outlining confidence in primary care to effectively and appropriately manage their holistic needs. The evaluation also showed that clinicians felt assured by the process of receiving specialist advice when needed. Finally, clinical safety was achieved through the maintenance of the prostate register which mitigated patients being “lost” within the system. 2. Outcomes2.1NHS Outcomes Framework Domains & IndicatorsDomain 1Preventing people from dying prematurelyYESDomain 2Enhancing quality of life for people with long-term conditionsYESDomain 3Helping people to recover from episodes of ill-health or following injuryYESDomain 4Ensuring people have a positive experience of careYESDomain 5Treating and caring for people in safe environment and protecting them from avoidable harmYES2.2 Expected outcomes It is intended the following outcomes will be achieved via commissioning of a Primary Care Prostate Follow-up Service Improve quality of care through personalised care closer to home Improved patient experience – monitored through patient surveys Increased ability for patients to self-manageImproved professional satisfaction both primary and secondary careReduce follow up and reviews in hospital Provide a local cost-effective service 3. Scope3.1Key aims and objectives of serviceAimsThe aims of this service to provide an enhanced support for prostate cancer patients in the community including annual holistic needs assessments (HNAs) and PSA monitoring, will support the strategic objectives of moving care closer to home and delivery of productivity savings. ObjectiveImprove quality of care through personalised care closer to home Improve patient experience and access to other services for better outcomes by embedding a supportive/holistic element to needs assessment, as part of the follow-up service.Improve follow-up processes to shift care from secondary to primary care for stable prostate cancer patients in the catchment areas of North Central London CCGs.Bringing care closer to home by facilitating primary care follow-up. Review and revise information given to patients about their follow-up care in order to enhance knowledge of prostate cancer, consequences of treatment and promote self-management where possible. To identify patients whose disease has progressed and ensure rapid referral back into secondary care for review.Ensure PSA monitoring at least six monthly or more (e.g. annual) for suitable patients as recommended by protocol.Improve the first to follow up ratio in the acute trusts which will lead towards releasing consultant and specialist nurses to focus on new appointments including improvement in cancer wait targets and delivering holistic needs assessments in patients with advanced disease. Provide Training and development for primary care professionals on prostate cancer and the needs of patients living with and beyond prostate cancer. More timely identification and management of consequences of treatment by the primary care team that is sustainable.NCL CCGs will contract with individual practices or federations. Where surgeries wish to provide this collaboratively for their registered population, they can make local arrangements to manage this between themselves as the contract will be with individual practices. It is expected that the service is offered to all patients unless patients choose to opt out.3.2Service description/care pathwayThis specification outlines the more specialised care required over and above what is normally provided through essential and additional services that General Medical Services are contracted to provide. No part of this specification by commission, omission or implication defines or redefined essential or additional services. Transfer of Patient The responsibility for transfer should be by Secondary Care with active selection of patients eligible for primary care follow up. In addition, GPs that are willing to proactively identify eligible patients on their patient lists can send this list to secondary care for review and subsequent transfer if the patient’s named Consultant in agreement. See Figure 1 for pathway diagram and Appendix 7 for a guide to proactively identify suitable patients. The Urology Departments at UCLH, Royal Free, Whittington Hospital and North Middlesex Hospital will take responsibility for ensuring that the patient has been transferred, pending agreement from the consultant. The GP will be informed when this has been completed and will receive a HNA and Treatment Summary. Figure 1: pathway diagram3.2. 1 Requirement from Primary CareThe primary care provider will be required to:Develop and maintain a prostate cancer follow-up register which must include an active recall system and include all prostate cancer patients with READ code B46 or B834 and are not under secondary care.Offer a 30 minute ‘welcome appointment’ to all newly transferred patients within four weeks of notification transfer from secondary care with the primary care nurse or GP. This is an opportunity for the practice to start a holistic care plan for long term conditions management of the patient (Appendix 2 for sample Treatment Summary and Appendix 4 for sample letter to patient and patient held holistic care plan) which should be reviewed at subsequent follow-up consultations. Identify a named clinical lead (GP or Nurse) who should attend locally arranged training, complete a minimum 1 hour training session accredited by BMJ Learning and disseminate training material to other staff within the practice. Recommended modules availableSignpost patient to resources to promote self-management of symptoms such as fatigue and incontinence as well as signposting to appropriate services to be made available for patients. PSA levels are checked against patient specific “normal ranges”/parameters as per their treatment summary. Lab normal ranges may not reflect patient specific threshold. Patients are informed of their results by the practice. If patients need to be referred back to secondary care via the 2ww route, practices will ensure patients are advised of the referral and to let practice know if a clinic appointment hasn’t been booked within 14 days. Any patient failing to make an appointment or failing to attend for the review consultation will be followed up. Should a patient decline to follow up, this should be documented clearly in the patients’ record and on the Prostate Register together with reason stated for patient’s opt out and should be re-invited at least annually.The responsibility for managing the care of the patient on the prostate cancer register will be deemed to be their registered GP although the service may be delivered by another clinician in the practice or GP in another nominated practice. The agreed protocols for management of patients with prostate cancer stable on treatment will be adhered to for the management of every patient. It is the provider’s responsibility to ensure that the protocols used reflect the most up to date version.Other requirements for providers to adhere to are as follows:The service needs to be patient-centred and accessible Services will be provided by trained and qualified practitioners with appropriate equipment.Provider will not discriminate between or against patients/carers on the grounds of age, ethnicity, disability, religion, or any other non-medical characteristicsReasonable adjustments and variations in service must be made for those with a disability – this may include reserving beginning or end of session appointments where suitable. Any significant issues relating to this service should be reported to the CCG and any complaints into the service will be investigated as outlined under quality contract.3.2.2 Data CollectionAny activity carried out under the contract will be recorded in the electronic patient record using the appropriate Read Code. Brief intervention advice should be offered as and when appropriate and any significant events to be managed in line with practice protocol. Annual Data to include:Total number of patients listed on GP register that have prostate cancer who are managed in primary care with the READ code 8Hgg2 The total number of patients that have had an annual holistic review recorded with READ code-389HThe number of patients who have not had a PSA test for 18 months Number of patients referred back to secondary care Patients coded with READ code 8Hgg2 that have deceased together with date of death Appropriate Read Codes have been provided (See Appendix 5)3.2.3 Education & Training The named clinical lead (GP or Nurse) is expected to complete a one-off minimum 1 hour training session accredited by BMJ Learning and disseminate training material to other staff within the practice.3.2.4 Review & Quality Assurance Practices must use appropriate escalation procedures within their surgeries to ensure any matters arising are recorded and appropriately managed.Where necessary and appropriate, timely escalation should be made to the CCGA summary of such matters arising in relation to this service as above should be provided as part of the annual report to the CCG. 3.3 Population covered, Location and timing of servicesThe service is available at GP Practices and is for service users who are registered with a General Practitioner (GP) in Barnet, Camden, Enfield, Haringey and Islington.3.4 Acceptance and exclusion criteria Eligibility criteriaAll stable prostate cancer patients registered with a Barnet, Camden, Enfield, Haringey or Islington GP will be considered for entry onto the prostate supported self- management pathway unless the individual: Is on active surveillanceIs being treated with brachytherapyIs at high risk and has had radical radiotherapy or surgeryIs being treated with focal therapyFor individuals participating in clinical trials, follow-up will be determined by the clinical trial protocols. All individuals taking part in trials will still access and benefit from the end of treatment clinical OPA (outpatient appointment) and health and wellbeing events.Definitions of stable have been developed and agreed per treatment. They are as follows: Localised Prostate Cancer – Watchful Waiting: All patients after 1 year of diagnosis who are willing and able are to be considered for self-management.Patients who have had curative radical prostatectomy: All patients 1 year after treatment and have undetectable PSA.Patients who have radical radiotherapy: All patients 2 years after treatment and PSA is less than 2 ng/ml above nadir. This is within the context of normal testosterone levels.Patients being treated with hormonal treatment only for locally advanced disease: All patients 1 year after treatment whose PSA is less than 2 ng/ml. 4. Applicable Service StandardsThe service will be delivered according to best practice and in line with the relevant local and national guidance4.1 Applicable national standardsCompliance with relevant guidance and policyThe service must comply with the guidelines produced by the following organisations (where applicable):Rules of Professional Conduct Guidance and recommended pathways National Institute of Clinical Excellence (2014) Prostate Cancer: diagnosis and management National cancer survivorship initiative (2013) Stratified. Pathways of care. Available: All practices should be aware of the NICE end of life care for adults Qualitystandards and adhere to them in their practice. Quality Commission registration requirements4.2 Applicable local standardsAs referred to in this document and as developed by providers to ensure that there is an operational level for self-certified protocols.London Cancer Prostate Cancer Stratified Follow-up Implementation Resource Pack 5. Key Service Outcomes & Tariffs5.1 Tariff descriptionFor 2017/18 a year of care payment of ?50 per patient with prostate cancer will only be paid for those who have had a holistic needs assessment and PSA (or exception code) recorded.This payment will be made at the end of the year (April 2018) and will be based on a completed template including prostate cancer patients, indicating latest date of PSA and HNA both of which should have been within year. Also to include, if applicable, date of transfer from secondary care and date of death if within year. There is an expectation that all practices delivering the service send a clinical representative to complete an online module at the beginning of the project and attend annual CCG updates on cancer when invited. As part of contract management with all providers the CCG may carry out random verification visits during the course of the year to validate data submitted for payment under this scheme.? Practices will be notified in advance if they have been selected for a visit. Where data cannot be validated, the CCG will seek to recover the payment.List of appendices: PageAppendix 1: Sample Transfer/Discharge letter to GP 9Appendix 2: Sample Treatment Summary10Appendix 3: Follow-up Guidelines for Managing Stable Prostate Cancer in Primary Care11Appendix 4: Sample Letter to patient and holistic care plan 12Appendix 5: List of READ CODES14Appendix 6: Holistic Needs Assessment Protocol for Prostate Cancer Follow-up15Appendix 7: How to Guide for practices to identify suitable patients 20Appendix 8: Re-referral protocols and advice lines 225131435-6159500Appendix 1: Transfer/Discharge Letter and Treatment SummaryToday’s Date:Patient Name:DOB:Hospital Number:NHS Number:Dear Dr ………………………………………………….After having treatment for prostate cancer at Trust Name, Mr xxxxxxx is now being discharged to primary care.Consequences of Treatment: (outline here any consequences of treatment such incontinence, erectile dysfunction, bone pain, lower limb lymphoedema, etc.) ………………………………………………………………………………………………………………………………………………………………………………………………………………..Referrals to support services: (outline here any support services patient is attending in relation to any consequences of treatment, such as rehabilitation, ED clinics, etc) …………………………………………………………………………………………………………....................................................................................................................................................................Please find enclosed a copy of their treatment summary and care plan which outlines what was discussed with them. Your patient also has a copy of this.As part of your patient’s on-going care, they will need: FORMCHECKBOX PSA tests every [Add frequency of PSA test here]. The next PSA date will be [Insert Month/Year] FORMCHECKBOX Please refer back to the Urology team if PSA rises above [Add PSA value here]For any queries, please contact our Urology Cancer Team on [insert specialist team number]Signed: .................................................... Contact telephone no. ..............................................Name (please print) ....................................................................GP Name: _______________________________________________________5116195508000Appendix 2: Sample Treatment Summary Dear Dr XRe: Add in patient name, address, date of birth and record numberYour patient has now completed their initial treatment for cancer and a summary of their diagnosis, treatment and on-going management plan are outlined below. The patient has a copy of this pleting Doctor: Signature: Date:4936490000Appendix 3: Follow-up Guidelines for Managing Stable Prostate Cancer in Primary CareThese are guidelines only, based on Prostate Cancer NICE guidelines and the National Cancer Reform Strategy. Clinicians can choose to make different decisions according to individual patients when appropriate.Localised Prostate Cancer – Watchful WaitingPrimary care follow-up: Welcome appointment and annual Holistic Needs Assessments. PSA tests every 6 months – annually from year 3 post diagnosis.Trigger for Urology re-referral: PSA is greater than 2ng/ml. A member of the Urology MDT should review men with localised prostate cancer who have chosen a watchful waiting regime and who have evidence of significant disease progression (rapidly rising PSA or bone pain) as per NICE guidance (2014)Patients who have had curative radical prostatectomy Primary care follow-up: Welcome appointment and annual Holistic Needs Assessments. PSA every 6 months following treatment - annually from year 3 post treatment.Triggers for Urology re-referral: Any detectable PSA (PSA greater than 0.01ng/ml).3. Patients who have had radical radiotherapy These patients may have recurrence of their prostate cancer years later. Primary care follow-up: Welcome appointment and annual Holistic Needs Assessments. PSA every 6 months following treatment - annually from year 3 post treatment.Trigger for Urology re-referral: PSA greater than 2ng/ml above nadir.4. Patients being treated with hormonal treatment only for locally advanced disease: Primary care follow-up: Welcome appointment and annual Holistic Needs Assessments. PSA every 6 months following treatment - annually from year 3 post treatment.Trigger for Urology re-referral: PSA greater than 2 ng/mlTo refer back to secondary care, please complete the ‘NCL Prostate Cancer Re-referral Form’Email contact details for clinical queries -UCLH: urology.queries@uclh.nhs.ukWhittington: Paul.erotocritouy1@RFH: rf.prostatenavigator@NMUH: northmid.urology@GP Practice Address / Letterhead:Contact telephone number:Dear___________Information regarding your Prostate Cancer follow-up careYou have been receiving care from your hospital consultant for your prostate cancer. Your consultant has informed us that your care can now be transferred to your GP instead of attending the hospital for appointments. This will involve regular appointments for blood tests and a yearly discussion to see how you are getting on. The blood test will be for PSA levels. This is a simple blood test and will be carried out here at the GP practice. Your consultant at the Hospital will have advised your doctor what level your PSA is and what increases would mean you might need further investigation. You should have received a copy of this letter, if not please ask your GP or nurse for a copy of it.If any problems develop in the future we will immediately discuss them with your hospital consultant. Your next check-up is due in: --/-- (month/year)We will contact before the appointment date in order to arrange a blood test prior to this appointment. We would like to offer you an appointment with one of our practice nurses between now and your next appointment to discuss any concerns or support. We have attached a Prostate Cancer Care Plan for you to think about three main issues you would like to discuss. Please bring this Care Plan with you so that the Practice Nurse or GP can go through the points you want to discuss and give you further information about relevant services. If you have any concerns about your health before your prostate follow-up appointment, please book an appointment to see a GP in the usual way. We look forward to seeing you at the practice.Yours sincerelyGP name and signature CC: Consultant name APPENDIX 4Prostate Cancer Care Plan (please bring this to your next prostate cancer appointment)We have asked you to complete a Prostate Cancer Care Plan. This provides us with information to give you the best support to manage your condition. This document lists some issues / concerns. Please indicate if any apply to you and if so which you would like to discuss at your next prostate cancer review with your GP/Practice Nurse.Physical Concerns Yes No Discuss Practical Concerns Yes No Discuss Relationship Concerns Yes No DiscussProblems when urinating ? ???? Caring for others????????? ????? With children ? ??? or loss of bladder control With partner ? ??? Loss of Bowel control ? ??? Housing or finances ? ?????With others ? ??? 6859905172085 Concerns Loss of faith or ? ??? other spiritual concernsLoss of meaning or purpose in lifeRegret 00 Concerns Loss of faith or ? ??? other spiritual concernsLoss of meaning or purpose in lifeRegret Constipation or diarrhoea ?????????Parking or transport ? ??? Spiritual /religious Yes No Discuss Bleeding from the bowel ? ????? Work or education ? ???????7008638268645Please write down anything else you wish to discuss with the GP or Practice Nurse:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….00Please write down anything else you wish to discuss with the GP or Practice Nurse:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Poor appetite ? ???????Grocery shopping or making food ? ??????Indigestion ? ???????Bathing or dressing ? ???Bone pain ? ???????Laundry or housework ? ????Feeling tired ? ???????Information needs ? ???? Poor sleep ? ???????Emotional Concerns Problems getting or keeping an erection ? ??????? Loneliness or isolation ? ???? No or loss of sex drive ? ??? Sadness or depression ? ??? Unplanned weight gain or feeling swollen ? ??? Worry, fear or anxiety ? ???Unplanned weight loss ? ??? Helplessness ? ??? Prostate Holistic Care Plan for________________________________________________ (Patient’s name.)After discussing my holistic needs these issues were identified and discussed:NumberissueSummary of discussionAction required /by (name and date.)Signed (Patient) _______________________________________________________________________________________Date_______________________ Signed (Healthcare professional) _________________________________________________________________Appendix 5: Read codes EMIS / VISIONREAD CODEMalignant neoplasm of the prostateB46Carcinoma in situ of the prostateB834Holistic Needs Assessment (if patient is offered and declines holistic needs assessment then enter READ code with “declined “ in free text-389HLab test not necessary (where PSA testing is not appropriate)411Prostate Specific Antigen43Z2Discharged from secondary care prostate cancer /urology services8Hgg2Appendix 6: Holistic Needs Assessment Protocol for Prostate Cancer Follow-up(Annual)PROSTATE CANCER ACTIONRATIONALEIntroduction:Practice Nurse to introduce her/himself to patient, review patients End of Treatment Summary & Follow Up Protocol where applicable and confirm that it is the correct patient. Offer partner or carer to be present at consultationTo ensure that the patient is fully aware of the purpose, duration and frequency of follow up Discuss patient’s immediate concernsTo ensure that follow up care is patient centred which takes into account the individual needs of the patient and his partner/carerDiscuss and explain PSA and any other relevant blood test results and action as per patient protocol. To monitor PSA in accordance with End of Treatment Summary & Follow Up Protocol where applicableAssess for specific prostate cancer disease or treatment related issues: Lower Urinary Tract Symptoms (LUTS): Treatments for prostate cancer may cause problems which affect the lower urinary tract. These symptoms can vary in severity and frequency and for some men they will be very troublesome. Access to self-management strategies and specialist continence services when necessary are available. when assessing the patient please consider the following:Using the International Prostate Symptom Score (IPSS) to identify and monitor LUTS Exclude symptoms of urinary tract infection (UTI), if a UTI is indicated then perform a multi-stix urine dipstick send a mid-stream urine sample for analysis as indicated and treat appropriatelyEncourage regular pelvic floor exercises, re-educate and offer factsheetDiscuss lifestyle changes - Maintaining a healthy weight, avoiding constipation and avoiding heavy lifting will reduce the pressure on the pelvic floor. If the patient smokes, encourage them to stop as coughing puts pressure on the pelvic floorAdvise to drink plenty of fluids and avoid or reduce fizzy drinks, caffeine and alcohol as these may also irritate the bladderDiscuss pharmacological management with GPConsider referral onto to the local Adult Bladder and Bowel Care ServicesAdult Bladder & Bowel Care ServicexxxxxxxxxxxxxxxxxxxA referral form, patient and healthcare professional information can be downloaded from their website by visiting:xxxxxxxxxxxxxxxBowel symptoms: Radiotherapy and brachytherapy can cause the lining of the bowel to become inflamed, which can lead to symptoms such as loose stools, frequency, urgency and bloating. These symptoms usually settle down after a few months but can return years later. When assessing the patient please consider the following: Eating less fibre in the diet for a short while may be of benefit. The patient may need guidance on types of food to eat; suggest white bread, white pasta, white rice, potatoes without skin and lean white meatThe men would have been given a diet sheet from their Cancer Centre prior to their treatment, if they follow this again for a short while symptoms are likely to improveIf symptoms persisting or rectal bleeding is present discuss with GP/Practice Nurse and consider further investigations with specialist teams with expertise in radiation induced enteropathySexual dysfunction: Prior to treatment men and their partner’s would have been made aware of the potential difficulties they may encounter following treatment. They may experience a reduction in or loss of erectile function, loss of libido, pain on orgasm. There are various treatments and support available, please consider the following when assessing the patient:Explore with the patient whether sexual dysfunction is an issue for him or his partnerMen with prostate cancer get free medical treatment for problems with erections and sexual functionPhosphodiesterase type 5 (PDE5) inhibitors should be considered first. However, there are other ways to manage erectile dysfunction which include intraurethral inserts, penile injections, vacuum devices and penile prostheses.Offer patient appointment with GP to discuss treatments for erectile dysfunction and consider referral to the local Erectile Dysfunction Clinic. This can be done through the GP.Offer psychological support at the local Health and Wellbeing Services or in complex cases refer for local Psychosexual Counselling at:Clinical AdministratorPsychosexual ServicexxxxxxxxxxxxxxxxxxxxxxTel: xxxxxxxxxxxxxxxxxxxxxxxHot Flushes: Hot flushes are a common side effect for men who are on hormone deprivation; they will differ in frequency and severity. If troublesome then please consider the following:Patients may recognise a trigger to the hot flushesLifestyle changes - stopping smoking, maintaining a healthy weight, drink 1 – 1.5 litres of water a day, reduce caffeine, reduce spicy foodWear cotton cloths and use cotton sheetsConsider herbal remedies such as Sage Tea or Evening Primrose Oil. Acupuncture may also help.Offer the PCUK booklet ` Living with hormone therapy, a guide for men with prostate cancer`Fatigue: Fatigue is a common side effect following a diagnosis of cancer and its treatment. It is not usually relieved by resting and it is recognised that fatigue can impact on the physical, emotional and social aspects of an individual’s wellbeing. Regardless of the cause there is help and support available. Please consider the following:Explore with the patient the impact fatigue is having on his day to day life Things which may help – taking regular exercise, prioritise and plan activities, eat a regular well balanced dietOffer Macmillan Fatigue bookletConsider referral to local Health and Wellbeing Services; Fatigue Workshop and Physiotherapy sessionsTo ensure that troublesome symptoms related to disease or treatment are assessed, diagnosed and treated appropriately Promote supported self-management and health and wellbeing services and refer as applicable to:Metro Walnut Support provides support for gay and bisexual men with prostate cancerSimon Faulkner on 07947 826 853 (Mon to Thurs 10-4), simon@, .uk.ukTo promote an empowerment and self-management model of care with the overall aim of improving health, independence and confidenceCarer Support – Carers play an important role in supporting men with prostate cancer, there are numerous individual and groups sessions available within your local Health and Wellbeing Centers which may be of benefit. Carers will also be offered an assessment using the Carer Support Needs Assessment Tool (CSNAT). The assessment tool has been developed to identify the support that is most appropriate to the individual in their role as a carer. To ensure that individual carers needs are identified and Document consultation and update patient held record as appropriateTo ensure that individualisedArrange next appointment and ask patient to have PSA blood test 2 weeks before next appointmentOffer open access and support as requiredIdentification of suitable patients from primary care - a How to GuideRun a search using the following read codes to be used to identify patients who have a diagnosis of prostate cancer/suspected prostate cancer on watchful waiting. The search terms are broad to ensure that all possible patients are identified. It is recommended that no time frames are added to the search.EMIS WebVisionMalignant neoplasm of the prostate B46Malignant neoplasm of the prostate B46History of prostate Cancer ZV104-5History of prostate cancer 1427000Carcinoma of prostate in situ B834Carcinoma of prostate in situ B834Suspected prostate cancer 1J08Suspected prostate Cancer 1Jo8The read codes below can be added to detect patients who may have been incorrectly coded or where prostate cancer is very likely but patient has declined /or is not suitable for biopsy.Raised PSA R15y0-1Raised PSA R15Y011Prostatism K20-6Prostatism 1AA and K20.16A clinician then needs to review the records of those patients identified, to assess suitability for primary care follow up.All stable prostate cancer patients registered with a Barnet, Camden, Enfield, Haringey or Islington GP will be considered for entry onto the prostate supported self- management pathway unless the individual:? Is on active surveillance ? Is being treated with brachytherapy ? Is at high risk and has had radical radiotherapy or surgeryFor individuals participating in clinical trials, follow-up will be determined by the clinical trial protocols. All individuals taking part in trials will still access and benefit from the end of treatment clinical OPA (outpatient appointment), and recovery package interventions. Definitions of stable have been developed and agreed per treatment. They are as follows: Localised Prostate Cancer – Watchful Waiting: All patients who are willing and able are to be considered for self-management. Patients who have had curative radical prostatectomy: All patients 1 year after treatment and PSA is <0.1 ng/ml above nadir. Patients who have radical radiotherapy – aim PSA <0.1: All patients 2 years after treatment and PSA is <2 ng/ml above nadir and no complications. Patients being treated with hormonal treatment only for locally advanced disease with or without metastases: All patients 1 year after treatment whose PSA is less than 4 ng/ml. Patients who have received focal treatment: All patients 1 year after treatment and no complications. Consultant will set individualised ceiling for PSA at this time. Reference: National Institute for Clinical Excellence (2014) Clinical Guidelines 175, Prostate Cancer Diagnosis and Treatment. Available: 8: Re-referral protocols and advice lines NCL PROSTATE CANCER RE-REFERRAL FORM REFERRAL?DATE:?? FORMTEXT ?????Please email or send e-referral within 24 hours. Refer back to the MDT that previously managed the patient. List of emails addresses embedded here:\sFax is no longer supported due to patient safety and confidentiality risks. PLEASE NOTE THAT AN APPOINTMENT SHOULD BE BOOKED WITHIN TWO WEEKS (they will be processed by the local 2WW offices, but are not 2WW referrals)PATIENT DETAILSSURNAME:?? FORMTEXT ????? FIRST?NAME:?? FORMTEXT ????? TITLE:?? FORMTEXT ????? GENDER:?? FORMTEXT ????? DOB:?? FORMTEXT ????? AGE:?? FORMTEXT ????? NHS?NO:?? FORMTEXT ????? ETHNICITY:?? FORMTEXT ????? LANGUAGE:?? FORMTEXT ????? FORMCHECKBOX INTERPRETER REQUIRED FORMCHECKBOX TRANSPORT REQUIRED PATIENT?ADDRESS:?? FORMTEXT ????? POSTCODE:?? FORMTEXT ????? DAYTIME?CONTACT:?? FORMTEXT ????? HOME:?? FORMTEXT ????? MOBILE:?? FORMTEXT ????? WORK:?? FORMTEXT ????? EMAIL:?? FORMTEXT ????? CARER/KEY WORKER DETAILSNAME:?? FORMTEXT ????? CONTACT:?? FORMTEXT ????? RELATIONSHIP TO PATIENT:?? FORMTEXT ????? COGNITIVE, SENSORY OR MOBILITY IMPAIRMENT FORMCHECKBOX COGNITIVE FORMCHECKBOX SENSORY FORMCHECKBOX MOBILITY FORMCHECKBOX DISABLED ACCESS REQUIRED PLEASE INCLUDE RELEVANT DETAILS:?? FORMTEXT ????? SAFEGUARDING FORMCHECKBOX SAFEGUARDING CONCERNS PLEASE INCLUDE RELEVANT DETAILS:?? FORMTEXT ????? GP DETAILSUSUAL?GP?NAME:?? FORMTEXT ????? PRACTICE?NAME:?? FORMTEXT ????? PRACTICE CODE:?? FORMTEXT ????? PRACTICE?ADDRESS:?? FORMTEXT ????? BYPASS:?? FORMTEXT ????? MAIN:?? FORMTEXT ????? FAX:?? FORMTEXT ????? EMAIL:?? FORMTEXT ????? REFERRING?CLINICIAN:?? FORMTEXT ????? REASON FOR URGENT PROSTATE RE-REFERRAL: FORMCHECKBOX PSA limit has been exceeded FORMCHECKBOX Re-Referral is due to CLINICAL CONCERNS (the GP MUST give full clinical details in the ‘additional clinical information’ box at time of referral)Additional clinical information:? FORMTEXT ?????Personal/relevant patient information:? FORMTEXT ?????Past history of cancer:? FORMTEXT ?????Relevant family history of cancer:? FORMTEXT ????? FORMCHECKBOX The patient has been advised and confirmed they will be available for an appointment within the next two weeksINVESTIGATIONSPlease ensure this referral includes ALL the relevant investigations. If there are any pending test results that you have organised at the time of this referral please provide information including TYPE OF INVESTIGATION requested (bloods, imaging) and TRUST performing the tests in the box below.? FORMTEXT ?????CLINICALLY-SPECIFIC AUTOMATIC TABULATED DATAPSA (All recorded values) FORMTEXT ?????OTHER (please provide details) FORMTEXT ?????Appendix 9: Where practices do not wish to participate in this locally commissioned service for their patients, the CCG will seek to work with neighborhoods to ensure appropriate alternative arrangements exist for those patients. It is expected that the service is offered and available to all patients unless patients choose to opt out.Appendix 10Community Services and Psychosexual servicesMacmillian Cancer information and support centreRFHDrop-in service?for anyone affected by, or who would like information on, every aspect of?cancer, including relatives and friends.?Managed by a Macmillan cancer information specialist and?supported by trained volunteers. Information is available in languages other than English, plus DVDs, CDs and Braille, and material?for children. Referrals can be made to other services, such as counselling and welfare benefits services.UCLHProvides advice and support to patients, families and carers on a wide range of information and support - advice about welfare and benefits, complementary therapy (massage, aromatherapy, reflexology, reiki and relaxation), dietitian, emotional and psychological support, wig fitting and scarf tying service.UCLH also provide support groups including Pillar Oncology Support Group and Haematology Support GroupRFHSelf-referralDrop in clinics - Mon 13:00 - 16:00, Tues - Thurs 10:00 - 16:00, Fri 10:00 - 13:00UCLHSelf-referralDrop in Mon - Fri 09:00 - 17:00Contact DetailsRFHGround Floor in Oncology out-patients department (do not need to be patient to access service)t: 020 7794 0500 x31337e: rf.cancerinfo@UCLHGround Floor, University College Hospital, Macmillan Cancer Centre, Huntley St, WC1E 6AGt: 020 3447 8663f: 020 3447 3825e:?supportandinformation@uclh.nhs.uk Community Specialist Palliative Care TeamsProvide specialist palliative and end of life care in the community to patients with life-limiting illness and offer support to families and carers.Address:-Community Specialist Palliative Care TeamsSouth Camden?(UCLH team)t: 020 3447 7140f: 020 3447 7677Out of hours -?t: 020 3456 7890 (UCLH switchboard, ask?to?air-call palliative care team)North Camden?(Royal Free team)t: 020 7830 2905?f: 020 7830 2045Out of hours -?t: 020 7794 0500 ext 23304 (Royal Free switchboard, ask to?air-call palliative care team)For handovers, preferred route is now Coordinate My Care (CMC).For?Bereavement support click hereFor Paediatric?Palliative Care (Life Force) click hereHow to ReferCommunity Specialist Palliative Care TeamsComplete Palliative Care Network Referral Form and select the correct optionSouth Camden - f: 020 3447 7677North Camden - f: 020 7830 2045Local HospicesComplete the Palliative Care Network Referral Form and select the correct optionMarie Curie Hospice - f: 020 7853 3438 (Outpatient) / 020 7853 3437 (Inpatient)North London Hospice - f: 020 8343 7672St John's Hospice - f: 020 7806 4041Local HospicesMarie Curie Hospice, Hampstead11 Lyndhurst Gardens, London, NW3 5NSDay services opening hours: Mon - Fri 09:00 - 17:00, Tues till 19:30t: 020 7853 3400f: 020 7853 3437e: hampstead.hospice@.ukNorth London Hospicet: 020 8343 8841f: 020 8343 7672e: nlh@northlondonhospice.co.ukSt John's Hospice60 Grove End Road, NW8 9NHt: 020 7806 4040f: 020 7806 4041e: @.uk?Additional support for GP practices from Dr P McDaid, Macmillan GP facilitator for Camden and Islingtone:?mcdaid@UCLHThe Lymphoedema service, within the Cancer Services Division, provides assessment, conservative treatment and management of cancer-related?lymphoedema.St John’s HospiceThe Lymphoedema Service treats primary and secondary lymphoedema due to any cause, as well as chronic oedema. Monday to Friday 09:00 - 16:00. Treatment aims to:prevent infection (cellulitis) and hospital admissionprevent Lymphorrhoea (leaking lymph fluid)reduce swelling and correct shape distortion of limbeducate and support patients to self-careimprove limb function/mobilityEligibility CriteriaUCLHAged 13 years and overCancer related lymphoedemaHaving/has had treatment for cancer under the care of UCLHSt John’s HospiceAged 18 years and over?Primary or secondary lymphoedemaHow to ReferUCLHReferrals via GP letter to:?Lymphoedema Service, UCLH, Cancer Services Division,?1st Floor Central, 250 Euston Road, NW1 2PGSt John’s HospiceReferrals can be by letter.?Please include a full medical historyf: 020 7806 4041Referral address: Lymphoedema Service, St John’s Hospice, 60 Grove End Road, NW8 9NHContact Details UCLHLymphoedema Service,?University College Hospital, Cancer Services Division, 1st Floor Central, 250 Euston Rd, NW1 2PGt: 020 3447 3925f: 020 3447 9055St John’s Hospice60 Grove End Rd, NW8 9NHt: 020 7078 3815f: 020 7806 4041Frail and elderly serviceThe CCG frailty team is continuing its work to integrate services across the borough for all frail and elderly people.Add patients at high risk of unplanned admission to the practice frailty register for?co-ordinated case managementThe locality MDTs now run regularly (see below). See?list for?meeting locations. GPs or practice nurses encouraged to visit and discuss patients. North Locality - every 4th Wed morning or lunchtimeWest Locality - every 4th Wed morning or lunchtimeSouth Locality - every 3rd Wed lunchtimeAll referrals to the MDT should be sent before 4pm on the Tuesday each week before the meeting to?mdt.admin@Care navigators are available in?practices, supporting vulnerable older people to get the right careThere are?4 education modules that can be completed -?GP Education Frail & Elderly. Upon completion a certificate will be issuedFor more information about prevention of falls?please refer to the Camden Integrated Network Checklist Care Navigation ServiceThe?service supports patients to gain access to voluntary and community services, and will focus on improving self-management wherever possible, as well as ensuring that vulnerable patients receive the right health and social care to meet their needs. Patients who are at risk of DNAs from key health and social care appointments can also be referred.Eligibility CriteriaThe service is suited to patients aged 60+, and either frail or pre-frail. Patients may have one or more long-term conditions, and may have had more than one?non-elective hospital admission in the last 12 months.?How to Refer Referral via EMISGP referral only - EMIS referral template attached.Please let your care navigator based in the practice know if you would like to book a visit on the number or email below. Each care navigator for your zone will be happy to guide you through the very quick referral service including answering any queries and showing you how to make referrals.Palliative care servicesPalliative care services aim to maintain and, where possible, improve the quality of life of patients and their families facing problems associated with life-threatening illness.Palliative care for adults:provides relief from pain and other distressing symptomsaffirms life and regards dying as a normal processintends neither to hasten or postpone deathintegrates the psychological and spiritual aspects of patient careoffers a support system to help patients live as actively as possible until deathoffers a support system to help the family cope during the patient's illness and in their own bereavementuses a team approach to address the needs of patients and their families, including bereavement support, as indicatedenhances quality of life, and may also positively influence the course of an illnessis applicable early in the course of any illness, in conjunction with other therapies that are intended to prolong life, such as in the case of cancer, chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complicationsTerrainLabelsAHillingdon Palliative Care Team Hillingdon Hospital, Pield Heath Road, Uxbridge, Middlesex, UB8 3NNmore service detailsBCamden, Islington ELiPSe and UCLH & HCA Palliative Care Service Camden and UCLH & HCA Services office: 2nd Floor Wing B, Maple House, 149 Tottenham Court Road, London, W1T 7NF Islington ELiPSe Service office: Unit D, Well House, 23a Benwell Road, London, N7 7BL Bladder and bowel (continence) servicesBladder and bowel (continence) services provide continence assessments and advice to people with bowel and bladder problems.Services aim to promote continence and provide a fully integrated service for the early identification, treatment and management of bladder dysfunction, with or without incontinence. The main remit of the service is to offer an advisory and educational role to other health professionals.Urinary incontinence is the involuntary leakage of urine and affects people of any age. The severity varies and although rarely life threatening, it may significantly affect quality of life. Types of incontinence include stress, urge, mixed, overflow, functional and chronic retention of urine with or without incontinence.Following the assessment we may offer treatment, advice, support and products or equipment where necessary. We will also refer you to other specialist services where appropriate.Eligibility criteria and referralsEligibility criteria and referrals vary according to location. For details, choose a service from the list below the map.TerrainLabelsA Harrow Specialist Adult Bladder and Bowel Service Contact Centre, Kirk House, 97-109 High Street, Yiewsley, West Drayton, UB7 7HJ more service detailsB Milton Keynes Continence Team Whalley Drive Clinic, Whalley Drive, Bletchley, Milton Keynes, MK3 6EN more service detailsCHillingdon Adult Bladder and Bowel Service Contact Centre, Kirk House, 97-109 High Street , Yiewsley, West Drayton, UB7 7HJ more service detailsLeafletsHealthy bladder advice (opens PDF) Healthy bowel advice (opens PDF) More informationNHS: bladder and bowel incontinence tipsNHS: bladder incontinence information and videoNHS: bowel incontinence information and videoTop of FormWe are committed to providing clear, simple information. Visit our easy read page for more information.District nursing servicesDistrict nursing services support patients who are housebound by providing nursing care in their own homes and/or other community settings.Services work in partnership with specialist community nursing and therapy services, patients, carers, general practitioners (GPs) and other social care teams to provide high-quality nursing care and advice.The service offers professional advice, support, teaching and skilled nursing care to enable people to live as independently as possible with an acute or chronic illness/disability who have a nursing needDistrict nurses assess the healthcare needs of patients and families, monitor the quality of care that they receive and are professionally accountable for delivery of care. They develop tailored packages of nursing care.The service also works to keep hospital admissions or readmissions to a minimum, and aids in the safe early discharge of patients from hospital into the community, wherever possible.District nurses also teach patients to care for themselves, and teach family members how to give care to their relatives.Eligibility criteria and referralsEligibility criteria and referrals vary according to location. For details, choose a service from the list below the map.Where can you find this service?Milton Keynes District Nursing Service more service detailsBHillingdon Ambulant Wound Care Service more service detailsCHillingdon District Nursing Service Contact Centre, Kirk House, 97-109 High Street, Yiewsley, Middlesex, UB7 7HJ more service detailsD Camden Integrated Primary Care ServiceContact Centre, South Wing, St Pancras Hospital, 4 St Pancras Way, London, NW1 0PEmore service details10) 11) Smoking Cessation Smoke free life Camden & Islington provide?group and one-to-one appointments for those who want to stop smoking. Additional support is available for?those who are housebound and or who may find it harder to quit - e.g. those with mental health problems, young people etc. The service runs stop smoking clinics across Camden and Islington,?and there are also community-based options for people who need more flexible services - e.g. weekends and evenings through pharmacy-based advisors (see Pharmacy List in Downloads).How to Refer Self Referral Referral via EMISComplete the Stop Smoking Referral Formf: 020 3727 0734Eligibility CriteriaBetween 14-64 yearsExperiencing first episode of psychosis of at least once week (unless curtailed by treatment before week is up)Period of psychosis accompanied by significant risk of decline in functioningNot taking antipsychotic medication for more than 6 weeks unless this was started in the last 3 monthsPeriod is not considered drug-induced (if client was initially well then acutely unwell following drug use, then made rapid recovery)Symptoms not wholly explicable in context of PTSD and/or Personality DisorderNot eligible if?clear organic cause for their psychosisHow to ReferComplete referral formt: 020 3317 6250e:?cim-tr.CamdenEIS@For second opinions or queries on referrals contact the Assessment and Advice Team:t: 020 3317 7300Contact DetailsEarly Intervention Service4 Greenland Road, London, NW1 0ASOpening Hours: Mon - Fri 09:00 - 17:00t: 020 3317 6590m: 077 1748 3754e: cim-tr.CamdenEIS@External Links HYPERLINK "" Camden Early Intervention Service Provided By12) Bladder & Bowel CareBladder and Bowel Care Service sees both adults and children (from age 3) who have bladder or bowel problems (including bed?and daytime wetting, constipation;?excluding stoma care). Teach pelvic floor exercises, bladder drill, intermittent catherisation.Locations include St Pancras Hospital and Kentish Town Health CentreAll housebound patients requiring a continence assessment for bladder and/or bowel management or assessment for products should be referred to district nurse in first instancePhysioLinePhysioLine can offer pelvic floor exercisesRoyal Free HospitalFor pelvic floor exercises please refer to the Women's Health PhysiotherapyIncontinence PadsFor supplies of incontinence pads, liaise with your district nursing teamHow to Refer Self ReferralBladder & Bowel CareComplete referral formReferral address: Central Booking Service Level 4, Highgate Wing, Dartmouth Park Hill, N19 5JGe: arti.centralbooking@Self-referral available - t: 020 3316 8401 ................
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