BIR Make It Better Service Award
The BIR Make it Better Service Award is given yearly to the group of people who have demonstrated the best improvement in an aspect of service delivery by making it more effective, or have improved patient experience. This might be an innovative design of a piece of kit or changes to a patient pathway that has improved patient comfort or made the pathway less invasive, reduced delays or improved the environment for the patient.
The Papillon Contact Brachytherapy Team at the St Luke’s Cancer Centre at the Royal Surrey Hospital NHS Foundation Hospital won the award in November 2020 for developing the “One-Stop Papillon Clinic”; providing advance patient information and enabling radiotherapy the day of initial consultation for patients travelling long distances for treatment
Low-energy contact X-Ray brachytherapy (CXB) also known as the Papillon technique, aims to improve treat rectal cancer using radiotherapy alone. The intention is to offer cure or improved local control. The procedure involves inserting an X-Ray tube through the anus and placing it in close contact with the tumour to kill cancer cells. Patients on average are given 3 fractions of CXB. This non-operative approach is chosen by patients who are unfit for radical surgery, elderly with co-morbidities or those with low tumours who wish to avoid the formation of a permanent stoma. Patients are often also treated with external beam radiotherapy which can be delivered at their local hospital. Patients are referred by surgeons who are aware of the technique or discover the treatment themselves by internet searches and ask their GPs to refer them.
The CXB service at the Royal Surrey County Hospital was set up in 2013 and is currently the sole provider in the South of England. Therefore the referral area is geographically wide, from an area reaching as far as Cardiff, Jersey or Kent. After gradually building up referrals, the service now treats an average of 50 patients per annum. The median age of patients treated at the Royal Surrey is 72 years of age. For most referrals we aimed for the time from initial discussion at MDT to the first appointment to be 2 days.
With the referral area being so wide, patients were travelling long distances for consultation regarding CXB treatment, then returning at a later date to undergo treatment. The patients are often elderly and relying on relatives or numerous changes on public transport to get to the hospital. The patient group were often well informed and came to the initial consultation knowing some information about the procedure. Patients started to indicate that if the service were available they would be happy to go straight for CXB treatment that day to minimise travel and expedite treatment.
Therefore, the service was re-configured to co-ordinate the patient’s outpatient appointment and their first fraction of Papillon on the same day. This worked towards the Trust’s True North and Breakthrough Objectives of “Aiming to improve the patient experience and reduce journeys made by patients”. However, a fair proportion of the first patients to be invited for same day treatment declined it. Further development of the service was required.
A new out-patient letter was drafted in which it clearly detailed that there was the possibility of CXB treatment being available on the same day as their initial appointment, if the patient was eligible for treatment. The new letter also informed the patient that they could be at the hospital for up to 4 hours, thus preparing them for extra parking charges or other travel arrangements.
The time between initial MDT and the first outpatient appointment was also extended by a week where clinically appropriate, enabling the more detailed letter and treatment DVD and leaflets to be posted to the patient.
Upon inception of the same day service it was realised that not many patients took up the offer of same day out-patient appointment and treatment. Upon investigation it was realised that patients, through lack of awareness, were totally unprepared for the same day treatment. The out-patient appointment letter did not inform patients that there was a possibility of treatment on the same day, therefore patients were anxious at the thought of making a decision to have immiediate treatment and felt rushed and uninformed. Out of the initial 23 patients 12 didn’t have same day treatment, thus another appointment a week later was made for treatment.
We had received charity funding to develop improved patient information regarding the treatment, including treatment booklets and a DVD. The patients didn’t receive until they were in the clinic room in front of the doctor and therefore couldn’t watch the DVD until they got home.
We also arranged for a Macmillan funded “Paps Buddy” to be available at the one-stop clinic. This is a former patient who is trained by Macmillan to provide decision support and counselling at the initial out-patient appointment. They give the new patient personal understanding of the Papillon process and are also able to answer “patient to patient” queries and concerns regarding treatment and the post-treatment time.