Analysis

Cancer care and COVID-19: how services have adapted to the challenges with online and community initiatives

Fear of the virus prevented many people from coming forward, but numbers starting cancer treatment are now on the increase

Fear of the virus prevented many people from coming forward, but numbers starting cancer treatment are now on the increase

  • As many as 50,000 cancer cases across the UK may have missed being diagnosed, according to one estimate
  • Nurses have been at the forefront of creative change as services adapted using online resources
  • But delays mean a high number of late stage cancers could be diagnosed in the future
Picture illustrates chemotherapy treatment. Fear of COVID-19 prevented many people from coming forward, but numbers starting cancer treatment are now on the increase
Picture: iStock

Partnership working, virtual appointments and expanded chemotherapy outreach are among the ways cancer services have been overhauled since the arrival of COVID-19 in the UK.

Now, services have finally got back to seeing the numbers of patients they were seeing before the pandemic hit.

Figures from NHS England released in early November showed the numbers starting treatment were back to their pre-pandemic levels.

People were deterred from seeking help because of COVID-19 fears

During the first lockdown, numbers dropped by one third – and have struggled to recover throughout the summer. It is a similar picture in Scotland, Wales and Northern Ireland.

While cancer care was not paused like routine surgery was during the first peak, services were severely disrupted and people were deterred from seeking help because of the fear of COVID-19.

Macmillan Cancer Support research suggests there may be as many as 50,000 cases across the UK that would normally have been diagnosed if it was not for the drop in numbers coming forward via GPs, screening and emergency departments.

50,000

Possible number of undiagnosed cancer cases in the UK during the pandemic

Source: Macmillan Cancer Support

High number of late stage cancers being diagnosed in the future

National Forum of Lead Cancer Nurses member Alison Keen says it is clear there will be a high number of late stage cancers being diagnosed in the future, but adds that the full restoration of numbers is ‘great news’.

‘We have had to work hard. Hospital sites have been reconfigured to create hot and cold areas. In a lot of places private hospitals have been used for surgery and chemotherapy, with staff moving across to new locations and adapting to new ways of working.’

NHS and private staff working side by side

When the pandemic hit, some of the cancer services at Norfolk and Norwich University Hospitals NHS Foundation Trust were moved to the nearby Spire Norwich Hospital.

Former nurse Linda Page who has helped out with cancer services at Spire Norwich Hospital during the COVID-19 pandemic
Linda Page

NHS nurses and doctors worked alongside staff at the private hospital providing surgery and chemotherapy. They were joined by Linda Page, a former nurse who had retired from her role as senior surgical matron at the trust two years ago.

Ms Page said: ‘I was loving my retirement, enjoying travelling and being busy. But when the pandemic hit I thought to myself there was maybe something I could do to help. I got a call and was quickly back working.

‘I’ve enjoyed being back among old colleagues and helping patients. The standard of care has been amazing.’

Chemotherapy has now moved back to the NHS site but surgery is still being done with around 30 patients a day being treated. The contract is due to end at the end of the year.

But Spire Norwich director of clinical services Louise Sokalsky says the site is ‘ready and willing’ to continue treating patients. ‘We will continue to have a role going forward. Services are under so much pressure still and there is a growing number of people waiting.’

Ms Keen says such moves have not been easy and have come at a cost. ‘IT systems are not that compatible and simple things such as ordering blood samples have become more difficult.’

She says her hospital – she is head of nursing at University Hospital Southampton NHS Foundation Trust – is now putting the finishing touches to a new cancer building, which is due to open early next year. ‘This is going to be used for chemotherapy, immunotherapy and outpatients, as we realise private hospitals will want their space back at some point.’

Partnership working has played a crucial part

But she says other areas have been able to adjust more easily. ‘Some regions that have a number of hospitals close together can designate entire sites, but that has not been possible everywhere.’

She also says partnership working has played a crucial part, with regional surgical hubs created so patients can be easily sent to other sites if there is a lack of capacity locally.

Changes have been seen elsewhere in cancer – with nurses often at the forefront. Through necessity, clinical nurse specialists started doing many virtual appointments in the first wave.

Platforms such as Attend Anywhere, Zoom and Microsoft Teams have been used for everything from regular check-ups to rehab and recovery courses, alongside telephone support.

Many of these arrangements have continued even as restrictions were relaxed.

Wales Cancer Network lead nurse Bethan Hawkes says: ‘The pace of change has been remarkable – we have done in months what it could have taken years to achieve.’

‘We have a lot of rural communities, so not having to travel can be a benefit’

‘It has helped reduce the numbers coming into hospital, which is important to limit risk and also alleviate the concern of patients who don’t want to come in.

‘For many it may prove to be a much better approach in the long term. We have a lot of rural communities, so not having to travel can be a benefit.

‘But we need to do a proper evaluation of this to see what impact it has had.’

Delivering chemotherapy and immunotherapy in the community

Over recent years, The Christie NHS Foundation Trust has been carrying out an increasing amount of chemotherapy and immunotherapy in the community. This includes running a mobile unit, outreach clinics in community venues such as hospices and providing treatment at home.

When the pandemic started, it expanded its services.

One of The Christie NHS Foundation Trust’s mobile units
One of The Christie NHS Foundation Trust’s mobile units

It added an extra day to the mobile unit rota providing treatment at the AJ Bell stadium in Salford on Mondays as Salford Royal Hospital had to close its chemotherapy unit. The service can treat up to 20 patients a day.

Two more nurses have also been taken on to provide treatment at home, bringing the size of the team to 12 full-time equivalents.

Patients find community services more convenient

The service is now able to treat 25,000 patients a year in the community.

Outreach manager Stephanie Hechter said: ‘We have been doing more in the community, but the pandemic meant we have had to expand it, perhaps at a more rapid pace than we probably would have done.

‘Patients say they like it as it is more convenient for them and in the current climate they would rather not be coming into hospital and sitting in waiting rooms.’

Barts Health NHS Trust director of cancer and palliative care nursing Alison Hill says in her experience the response has been mixed.

24,445

people in England started cancer treatment in September

Source: NHS England (2020)

Her trust has developed webinars offering health and well-being sessions for patients post-treatment.

‘We undertook a telephone survey of patients’ experience of telephone clinics – it was about fifty-fifty. Where it was an uncomplicated follow-up, patients valued not having to travel and avoiding coming into the hospital.

Calls often take as long as a face-to-face meeting

‘But where there was bad or complex news patients found it more difficult to raise questions and concerns about a change in symptoms. Many were also anxious about not having a physical assessment.’

‘People are having to come into hospital without their family there… We know older patients particularly struggle with this’

Alison Hill, director of of cancer and palliative care nursing at Barts Health NHS Trust

She says for cancer nurse specialists it can be more time consuming. ‘Calls often take as long and patients are also ringing in more often as they may not have understood previous information when not face-to-face.’

RCN Cancer and Breast Care Forum chair Nikki Morris says there are some great examples of creative thinking. But she too is worried it may have its downside.

‘My concern is that we have lost some of that holistic care. What made our cancer care outstanding was the excellent treatment, as well as the fact that nurses were there throughout the patients’ journey, supporting them and their families.

‘People are having to come into hospital without their family there. They are having check-ups done digitally or on the phone. That will suit some patients, but not all. We know older patients particularly struggle with this.’

‘It is important we don’t lose the holistic care. Cancer is difficult emotionally and mentally – and the challenge is even greater during the pandemic.’

Online cancer rehabilitation

The Royal Berkshire NHS Foundation Trust launched its online rehabilitation service for cancer patients in the spring.

Staff run one-on-one and group health and well-being sessions via videoconferencing.

Cancer rehabilitation lead nurse Kate Rawlings said: ‘It has worked well, and the feedback has been positive. We run the group sessions once a month for up to 20 people.

Picture shows a rehab patient looking at a tablet computer
A rehab patient Picture: iStock

‘We cover topics to support people to live well after cancer, such as managing fatigue, diet, exercise, relaxation and the psychological impact of cancer.’

One-on-one sessions are also available for patients who require more in-depth input where they can talk to a clinical nurse specialist, psychologist or consultant.

The service has set up a rolling programme of sessions on topics including complementary therapy, as well as financial and benefits advice with Citizens Advice.

Facial cues can tell you a lot

Ms Rawlings says: ‘Introducing change is difficult. In the NHS it can be like turning around a supertanker, but the pandemic left us with no option. It shows what can be done.’

She says one downside of the digital service is that with nursing, and cancer nursing in particular, the value of face-to-face contact is lost. ‘Things like facial cues can tell you a lot.’

Before the second lockdown the service had resumed one-on-one sessions in person for those who wanted them.

Ms Rawlings says the aim is to offer both options in the future.

The benefits of innovation in chemotherapy are perhaps more clear-cut.

Many places have increased the amount of chemotherapy and immunotherapy being carried out through outreach programmes, using a combination of community venues, mobile units and chemotherapy at home.

Ms Morris says: ‘We have always known patients welcome this and like not having to go into hospital. I have even heard of a chemotherapy unit being set up at a hairdresser’s that was no longer being used. There are lots of good examples out there. The creativity has been great to see.’

A push on more self-care with relatives and patients

UK Oncology Nursing Society president-elect Mark Foulkes agrees. He says there has also been a push on more self-care.

‘Some cancer centres have taught relatives and patients to flush lines and administer some of their own injections – these are things we may never have thought of before or would have taken ages to do. It has speeded up progress in many cases.’

22%

of people with cancer in UK saw treatment or care disrupted by the COVID-19 pandemic

Source: Macmillan Cancer Support (2020)

But with the UK deep into the second wave of COVID-19, concern is understandably being voiced that services could once again start to be hit.

Macmillan Cancer Support and Cancer Research UK have raised the issue in recent weeks.

By mid-November there were 15,000 patients in hospital with COVID-19, approaching the peak of the first wave when the numbers topped 20,000 at one point.

Some hospitals have already announced non-urgent surgery will be cut back.

Biggest risk is patients not coming forward again because of fear of COVID-19

At the moment cancer is being prioritised, but Mr Foulkes says there are a number of challenges on the immediate horizon.

‘We have got the pathways in place now and there is a real will to keep cancer services going… We are going to be okay’

Mark Foulkes, president-elect of the UK Oncology Nursing Society

He says these include a ‘bottleneck’ in accessing diagnostic tests, such as endoscopies and MRI and CT scans, as well as a ‘quite significant number of absences’ among staff who test positive or have to isolate because someone in their household is waiting for a test.

But the biggest risk, he says, is patients not coming forward again because of fear of COVID-19, despite cancer being more of a risk for many.

‘It is currently difficult to predict the effect of the second wave on patient confidence.’

But he is adamant that services will be ready as long as patients present: ‘It will be difficult. But we have got the pathways in place now and there is a real will to keep cancer services going. There is no talk of redeployment. I think we are going to be okay.’


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