The 'unacceptable' pressures of staffing and funding shortages on cancer care
Cancer Nursing Practice has been talking to nurses to find out how cancer services are being hit by funding and staffing shortages.
Cancer Nursing Practice has been talking to nurses to find out how cancer services are being hit by funding and staffing shortages
The House of Commons’ health and social care committee recently warned that the workforce needs to increase ‘at scale and pace’ if patients are to get the care they deserve.
Cancer Nursing Practice has been examining the evidence and talking to nurses on the front line to find out where the pinch points are in cancer care.
The committee cited a vacancy rate of 11% across the NHS in England, but there was no specific figure given for cancer nursing.
That is because the data is simply not there. Macmillan Cancer Support is currently carrying out an audit of the workforce that will be published in the spring.
of chemotherapy nurses’ time is spent supporting patients undergoing treatment
(Source: Cancer Research UK)
But it is already clear there are serious problems. England’s cancer strategy has called for every patient to be given access to a clinical nurse specialist (CNS) by 2020, however one in ten are not assigned one, according to the National Cancer Patient Experience Survey (NCPES).
The problems are most acute for prostate and urological cancers.
Chemotherapy nurse shortages are also being reported at Churchill Hospital in Oxford. According to the Times newspaper, a leaked memo circulated to staff at the hospital warned that it was having to delay chemotherapy treatment starting times because of a 40% shortfall of staff trained to deal with medication. Oxford University Hospitals NHS Foundation Trust refuted the reports, saying that while the memo set out the challenges to the trust’s service, it did not signal a change to formal policy for chemotherapy treatment.
Royal Marsden NHS Foundation Trust chief nurse Eamonn Sullivan says there is currently a ‘great demand’ for chemotherapy nurses, but he adds: ‘The biggest shortages are probably in critical care and theatre nurses. People are sicker and surviving for longer. The demand on these services has increased.’
Alison Hill, UK Oncology Nursing Society board member and lead cancer nurse at University College London Hospitals NHS Foundation Trust, says shortages cause real difficulties.
'The problem with vacancies in a specialist area like cancer is that you cannot just fill them with agencies. They simply can’t supply nurses who can give chemotherapy or fill in for CNSs. It means your staff have to work harder or you may need to review services.’
Lack of funding for training
A major problem for cancer services – as it is for the rest of the NHS across the UK – is retention.
University Hospital Southampton NHS Foundation Trust head of cancer nursing Alison Keen says lack of funding for training is one of the underlying causes. ‘There’s a clearly documented link between retention and the opportunity for development.’
of specialist cancer nurses are over the age of 50
(Source: Macmillan Cancer Support)
But she says hospitals simply have ‘no budget’ for this, leaving them to rely on charitable funds to pay for training, such as the masters-level qualification that CNSs need.
‘This has the obvious effect of reducing the opportunity for cancer nurses to achieve their potential,’ she says.
Prostate Cancer UK says the situation has got so bad that nurses are often having to use their annual leave and own funds to pay for the training they need to progress. It has called for a ‘development band 6’ to be created to establish a pathway to getting to the senior ranks of cancer nursing.
This is particularly pressing given the large number of cancer specialists reaching retirement age – one third are over the age of 50.
UK Oncology Nursing Society (UKONS) president Helen Roe says the number of retirees is already having an impact and exacerbating the number of vacancies. ‘When I look around, I see a large proportion of trained cancer nurses reaching retirement age.’
The non-specialist workforce
Lack of training is not just an issue for the specialist workforce. Last year, a report by Macmillan, titled Thinking Differently, cited the importance of non-specialists; from nurses on wards to staff working in the community, such as district nurses and practice nurses, given the growing numbers surviving cancer and the need to support recovery post-treatment.
But the charity’s research shows two thirds of Macmillan-funded staff do not feel patients get enough help to regain quality of life.
The most recent NCPES survey echoes this, with only six in ten patients feeling supported by staff at their general practice post-treatment.
RCN cancer and breast care forum chair Sue Cruickshank says working with and educating the non-specialist workforce is essential, pointing out that the college has produced a career and education framework setting out what skills are needed.
What is being done to support nursing
Following the criticism by MPs, health and social care secretary Jeremy Hunt pointed out that the government in England is overseeing the ‘biggest ever expansion’ in training places in the history of the NHS with the number of student places rising by one quarter this year to more than 25,000.
The pay cap is also being lifted, although full details of what sort of rise nurses will be offered have not been revealed yet.
Nursing associate roles are being piloted in cancer and a ‘homes for nurses’ scheme has been set up, giving 3,000 NHS workers first refusal on affordable housing generated through the sale of surplus NHS land.
NHS Improvement is also rolling out a retention programme, which involves direct support being given to half of hospital trusts, almost all of which provide cancer care to some extent.
Meanwhile, Health Education England has published a cancer workforce plan to help achieve the ambitions set out by the 2015 cancer strategy. It did not include detailed plans for nursing, but a follow-up chapter is being promised once Macmillan’s audit of the nursing workforce has been completed.
‘If potentially half the population is going to get cancer at some point in their lives, it is everyone’s business.
‘We need to go back to pre-registration and ensure cancer gets a profile commensurate with incidence.’
Filling in for others
The wider shortages in the health service have a direct impact on cancer nurses, says Macmillan chief nursing officer Karen Roberts.
‘Nurses working in cancer care are under unprecedented pressure with ever-increasing caseloads. But extreme pressures in the wider NHS mean that these specialists end up having to support their colleagues with tasks outside of their remit.’
She says this can include things such as chasing other professionals to speed up the discharge process.
Cancer Research UK has also been warning about this issue. Last year, the charity surveyed nearly 400 cancer nurses and they reported that only 15% of their time is actually spent supporting patients undergoing chemotherapy – the rest is spent on administration, planning treatment and carrying out patient consultations.
Meanwhile, half of CNSs said they did not have enough patient-facing time with demands forcing them to work an additional five hours each week.
The nature of cancer care means staff are placed under incredible pressure. The health committee mentioned nurses were not always able to take breaks and were constantly under the cosh.
But Sue Lennon, who has now left the NHS but worked as a nurse for 27 years, and most recently as a CNS, says it goes further than that in cancer.
She says at one point she got ‘so overwhelmed’ she had to take time off sick.
‘It’s hard to be the sponge, soaking up everyone’s distress. You need a place to put it or risk your own well-being.’
She says nurses need more support, something the cross-party group of MPs recognised too with their call for NHS England to establish a nursing well-being reference group.
One in ten
patients are not assigned a clinical nurse specialist
(Source: National Cancer Patient Experience Survey)
Mr Sullivan of Royal Marsden agrees more must be done to provide care and support to nurses.
He says working in such an intensive environment as cancer care can make people – particularly younger nurses – ‘re-evaluate their lives’.
He says his trust is responding to that by offering more flexible working, mentoring and even secondments abroad to allow nurses to travel and have time away.
But Dr Cruickshank says cancer nurses should also try to see the positives of working in this field, adding: ‘Yes it’s stressful and demanding, but it’s also rewarding. You have moments when you interact with patients and do something that impacts on their life – and the feeling you get from that is one that you don’t get in many jobs.’
How the Royal Marsden plugged the gap
Even the renowned Royal Marsden NHS Foundation Trust is not immune to the problems facing the sector.
Currently more than 10% of nursing posts are vacant with the most severe shortages in critical care and theatre nurses.
But that is still much better than the picture a year ago. Then 16% of posts were unfilled.
The shortfall has been rectified through a sustained approach, which has seen the trust recruit 190 nurses in just under one year.
An international recruitment drive was launched which saw the trust bring in ten nurses from the Philippines.
There has also been a push to get foreign nurses working at the trust as healthcare assistants (HCAs) while they await their admission to the nursing register in the UK. A group of 20 are being supported.
But by far the biggest source of recruitment has been from the British market via jobs fairs.
The trust makes much of the diversity it can offer in cancer care from working in critical care or theatres to spending time in the community or on medical day units. The trust runs a rotation scheme that allows nurses to spend six months in three different departments and also promotes flexible working to improve retention.
The hospital is also thinking long term. Admin staff and ward clerks have been encouraged to become HCAs and the trust is also part of the nursing associate training pilot – there are 18 people going through that process.