CHAPTER 8
8.1. Introduction
A broad objective of this Strategy is to have models of care in place that ensure that patients receive the required care, in a timely fashion, from an expert clinical team in the optimal location. The concept of a continuum of care underpins the approach to patient services, from prevention, early diagnosis, through evidence-based high quality patient-centred treatment, to appropriate follow-up and support.
A number of elements can be set out as design attributes of a system that has this continuum approach to the model of care as follows:
• Multidisciplinary care should be the cornerstone of cancer care: patients should have their diagnosis confirmed and their treatment planned in designated cancer centres by multidisciplinary teams of doctors and other professionals appropriate to the cancer type;
• Cancer patients should have access to high quality care staffed by appropriate specialists. While this should be as close to home as possible, centralisation of specialist services into the designated cancer centres is required to optimise outcomes for patients;
• Optimal cancer care should be closely integrated with a cancer research programme, including clinical trials;
• Planning for service delivery should address future demand as well as current needs, and should encompass the full patient pathway;
• Decisions on services should be evidence-based, with clear provision and accountability for the implementation of clinical guidelines and audit;
• Designated cancer centres should be networked to other elements of the health system to ensure that cancer control programmes are comprehensive;
• The integration of services across and within primary, secondary and tertiary care should be a priority;
• Referral pathways should be timely, and promote the early and prompt diagnosis and treatment of cancer;
• Patients and their families should be active partners in their care pathway and patients should have an informed choice on the treatments available;
• Services should be of a high quality and aim to deliver improved outcomes for patients based on the implementation of clinical guidelines; and
• Outcomes should be measured and reported upon regularly.
CHAPTER 8 PROVIDING AN INTEGRATED MODEL OF CARE
8.2. The Current Model of Care
Cancer treatment is primarily centred on referrals from GPs and smaller hospitals to designated cancer centres for diagnosis and treatment, with some limited referral back to local hospitals and GPs for follow-on care. With the growth in incidence and prevalence, there is a need to further develop patient pathways to ensure that high quality treatment, care and follow-up is provided in a more efficient and effective manner.
The current model of care for cancer treatment is centred on eight designated cancer centres serving a defined population and geographic area26. Chemotherapy is currently delivered mainly on a hub and spoke basis under the planning and supervision of the eight designated cancer centres. Radiation oncology is provided in the public system in Dublin, Cork, and Galway. Public access to private facilities is available in Waterford and Limerick, as satellites of the Cork and Galway services. Also, arrangements are now in place for patients from the North West to be referred to Altnagelvin Area Hospital in Derry for radiation therapy.
The current model of care also encompasses the role of GPs in primary care settings referring patients for investigation or diagnosis to local/regional hospitals or to designated cancer centres.
Since its establishment in 2007, the NCCP has worked to ensure that the pathway for cancer patients contains the following elements:
• Promotion of early accurate diagnosis;
• Primary, secondary and tertiary care services working closely together to:
} provide more cohesive and better care for patients with cancer;
} optimise arrangements for better co-operation and greater efficiency;
} share and collaborate actively to achieve goals;
} ensure multidisciplinary team engagement; and } effect smooth and timely transition from one service to
another; and
• Follow-on support after treatment.
8.3. Challenges for the Model of Care
8.3.1 Managing the expected growth in cancer cases The projected growth in incidence and prevalence of cancer will present a challenge for the current model of cancer care. A model of care is required that will be capable of managing the increase in cancer workload – from referral and diagnostics through to treatment and follow-up care – in a manner that provides safe, high quality care in clinically appropriate locations.
8.3.2 The need for improved integration in cancer services There is a need to ensure that patients, including patients
with metastatic disease, receive prompt referral, diagnosis and treatment in an integrated manner in order to ensure that outcomes are optimised. Equally, all treatment and post-treatment care should be planned and coordinated to ensure that there is a seamless transfer for patients between different settings. This includes survivorship care, psycho-oncology care, palliative care and end of life care. The need for improved integration across primary care and hospital settings was one of the key points arising from both the Evaluation Group and the public consultation.
PROVIDING AN INTEGRATED MODEL OF CARE
N AT I O N A L C A N C E R S T R AT E G Y 2 0 1 7 - 2 0 2 6
Improved integration requires patient pathways based on the different stages of cancer diagnosis, treatment and follow-up care, and taking into account specific cancer types. Based on the needs arising at each stage of the patient pathway, services can be aligned with appropriate local, regional and national locations. The concept of a networked approach to cancer care is important to ensure that each element of the patient pathway operates in an integrated manner. Designated cancer centres should be networked to other elements of the health system to ensure that cancer control programmes are comprehensive.
An integrated network approach, including the continued development of the nursing input, also facilitates the provision of services as close to patients’ homes as is appropriate.
Recommendation
The NCCP will further develop the model of care for cancer to achieve integration between primary care and hospital settings at all stages of the cancer continuum, from diagnosis to post treatment care.
Lead: NCCP
12
CHAPTER 8 PROVIDING AN INTEGRATED MODEL OF CARE
8.3.3 Increasing the level of specialisation in cancer care
Evidence of the positive relationship between higher case volume and better outcomes for patients has been demonstrated for many cancers and the Evaluation Group pointed to a need for further centralisation of cancer care.
Cancer care is becoming increasingly complex with the improved understanding of the genetic basis of some cancers and the development of more targeted treatments.
This is driving increased specialisation, with requirements for greater levels of clinical and scientific expertise.
The required focus on rare cancers will also increase the need for specialisation, given the relatively small number of cases, the complexity of treatments and the need for nominated clinicians to link with rare cancer networks overseas.
8.3.4 The role of patients in improving the model of care
The experience of patients can inform improvements in the model of care. Mechanisms will be developed to facilitate patient involvement in the design and review of services, including through the establishment of a Cancer Patient Advisory Committee. With the establishment of hospital groups, the potential exists for the better utilisation of hospital resources to provide services at clinically appropriate locations, governed by agreed patient protocols and pathways.
8.3.5 Towards an improved model of care
Designated cancer centres will play a key role in providing accurate diagnoses and in directing treatment pathways, as well as in the provision of tertiary cancer services. The establishment of these centres was a key outcome from the Strategy for Cancer Control in Ireland (2006) and the performance of the centres will continue to be monitored by the NCCP with a view to maximising throughput and outcomes.
The model of care being developed should also facilitate the use of local or regional hospitals for routine or less complex diagnostics, as well as for the provision of systemic therapy services (medical oncology and haematology) where clinically appropriate. However, where the diagnosis indicates a
requirement for more specialised treatment, typically with multi-disciplinary input, the pathway will be directly to the designated cancer centres.
The term quaternary care is sometimes used to describe services that are particularly specialised or carried out in only a very small number of locations. This model is currently applied where services for rare cancers are concentrated in a small number of designated cancer centres. The trend towards centralisation in a smaller number of designated cancer centres will continue for rare cancers and for common cancers where case volume, multidisciplinary working or infrastructural requirements are important determinants for patient outcomes.
8.4. Requirements to Improve the Model of Cancer Care
8.4.1 Develop the multidisciplinary care model in designated cancer centres
A Strategy for Cancer Control in Ireland (2006) recommended that patients should have their diagnosis established and their treatment planned by Multidisciplinary Teams (MDTs). MDT working is an essential cornerstone of cancer care internationally.
Key personnel from the various disciplines meet on a regular basis in a structured fashion to review and discuss newly diagnosed patients to plan their management and care. The care of individual patients is also discussed at other critical points in their care pathway, e.g. post-surgery or at relapse.
Significant progress has been made in establishing such teams in the cancer centres. MDT working has led to improved decision-making, more co-ordinated patient care and improvements in the overall quality of care. The treatment of patients whose cases are discussed at MDT meetings is more likely to be in accordance with clinical guidelines, and there is strong consensus that outcomes are likely to be better (KPI no. 12).
However, there is variation in the functioning of MDTs, with some more structured and better supported than others. To achieve equitable patient benefit from the process, the NCCP should review current MDT working to ensure that appropriate composition, resourcing, structures and procedures are in place, as well as reporting mechanisms to collect and analyse outcomes. In the future, guidelines on cancer care developed by the NCCP and endorsed through the NCEC’s guideline development process should include, where
appropriate, recommendations on the establishment and composition of MDTs.