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Project Initiation Document

The Gloucestershire Living With & Beyond Cancer Programme

Author(s) Kathryn Hall, Sadaf Haque, Alice Kennedy, Kelly Bluett, Hayley Payne, Sara Mathewson, Nikki Hawkins

Project Sponsor Dr Charles Buckley

Project Director Kathryn Hall

Project Manager Hayley Payne

Version no. 0.06

Project Aim

A cancer diagnosis is a life changing event and every person will have their individual needs for care and support and their own personal experience. We aim to create a sustainable and joined up change to ensure the best outcomes for our population and to enable people to live well with and beyond cancer. This document describes an overall programme of service improvement that has been pulled together by working collaboratively with the Gloucestershire Health Community, including Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT), Gloucestershire Care Services (GCS) and Gloucestershire Clinical Commissioning Group (CCG) and Macmillan.


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Contents 1 Document Control ...................................................................................................... 5

1.1 Version control ..................................................................................................... 5 1.2 Distribution ........................................................................................................... 5

2 Introduction ................................................................................................................ 5

2.1 Document purpose ............................................................................................... 5 2.2 Background .......................................................................................................... 6 2.3 A Note on Terminology ........................................................................................ 7 2.4 Context ................................................................................................................. 7 2.5 Definition of the Recovery Package ..................................................................... 9

2.6 Current Situation in Gloucestershire .................................................................. 11 3 Project Definition ...................................................................................................... 11

3.1 Overall Project & Programme Structure ............................................................. 11 3.2 Aims and objectives ........................................................................................... 13

3.3.1 Holistic Needs Assessment (HNA) and Care Plan (CP) .................................. 13

3.3.3 Treatment Summaries ..................................................................................... 14 3.3.4 Risk Stratified Pathways.................................................................................. 14 3.3.5 Community Cancer Care and Education Programme ..................................... 15

3.3.6 Primary Care Development ............................................................................. 16 3.3 Programme Scope ............................................................................................. 16

3.3.1 Inclusions ..................................................................................................... 16 3.3.2 Exclusions – include Phase 1 and 2 ............................................................ 17

3.3.3 Constraints .................................................................................................. 18 3.4 Anticipated benefits ............................................................................................ 19

3.5 Project success criteria ...................................................................................... 22 3.6 Assumptions....................................................................................................... 22 3.7 Interdependencies .............................................................................................. 22

3.8 Change control process ..................................................................................... 23

4 Project management approach ................................................................................ 23 4.1 Stages ................................................................................................................ 25

5 Deliverables ............................................................................................................. 26

6 Project organisation ................................................................................................. 27 6.1 Organisation chart .............................................................................................. 27

6.2 Gloucestershire Survivorship Steering Group .................................................... 27 6.3 Survivorship Project Board ................................................................................. 27

6.4 Project Team ...................................................................................................... 27 6.5 Working Group ................................................................................................... 28 6.6 Patient Reference Group ................................................................................... 28

7 Project communication ............................................................................................. 30 7.1 Introduction ........................................................................................................ 30

7.2 Stakeholder map ................................................................................................ 30 7.3 Stakeholder involvement .................................................................................... 31

8 Project budget and timescales ................................................................................. 31 8.1 Project budget .................................................................................................... 31 8.2 Key milestones ................................................................................................... 32 8.3 Overarching Programme Timeline ....................... Error! Bookmark not defined. 8.4 Holistic Needs Assessment and Care Plans Timeline ........................................ 32

8.5 Treatment Summaries Timeline ......................................................................... 33 8.6 Risk Stratified Pathways Timeline ...................................................................... 33 8.7 Education and Support Timeline .......................... Error! Bookmark not defined. 8.8 Community-Based Cancer Survivorship Project Timeline .................................. 34 8.9 Primary Care Development Timeline ................................................................. 34


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9 Risk and Issues ........................................................................................................ 35

9.1 Risk, Issues and Change Log ............................................................................ 35 10 References & web addresses ................................................................................ 35

Appendix 1 Project Management Products ................................................................. 36 Appendix 2 Project Quality Control and Configuration Management .......................... 38 Appendix 3 Roles and Responsibilities ....................................................................... 39


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Background Note on Project Initiation Documents

The information in the PID should answer the following questions:

What the project is aiming to achieve;

Why it is important to achieve it;

Who is going to be involved;

How and when it is all going to happen.

It is usual for the PID to go through several iterations before it is signed off by the Project Board. It will then be updated at the end of each stage of the project so at the end of the project the PID will describe the entire project. During the project you will use other templates to manage risks, communications and the project plan. The content of these templates will then be summarised in frequent Progress Reports to the Project Board.


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1 Document Control

1.1 Version control

Version Date Author/

Reviewer Comment

0.01 30/9/2014 Kathryn Hall

Preliminary draft to share proposed format and work in progress with clinical leads and programme team.

0.02 15/10/2014 KH Some additions to reflect project structure recommendations of CPG.

0.03 03/11/2014 Hayley Payne

Additions to definitions section on Recovery Package and objectives & benefits sections

0.04 07/11/2014 Hayley Payne

Stakeholder map updated and timelines added for key projects

0.05 13/01/2015 Hayley Payne

Appendices added and sections moved around. Information added from the launch event

0.06 27/01/2015 Hayley Payne

Aims and Objectives added for all projects and timelines included for overall programme and community-based service

1.2 Distribution

This document will be distributed to all members of the Cancer Clinical Programme Group, the Living With & Beyond Cancer Project Board (and other key partnership groups).

2 Introduction

2.1 Document purpose

The Project Initiation Document defines the scope of the project, the resources needed to complete the project and the project approach. It will outline how the project will be controlled to ensure it is delivered on time, on budget and to the agreed quality standards.

Our work on Living With and Beyond Cancer is a wider programme of closely interdependent system changes. This document is therefore something of a pragmatic hybrid, providing a development briefing on the wider work and serving as a formal joint Project Initiation Document for our keystone projects including:

Implementing the National Cancer Survivorship Initiative (NCSI) Recovery Package ( including Holistic Needs Assessments, Care Plans, End of Treatment Summaries and Education and Support programme) to support cancer patients across Gloucestershire.


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Introducing risk stratified pathways

Launching a community-based Cancer Survivorship Service (this will be done on a two phase basis; phase one will be within Gloucester City and North Cotswolds localities, and phase two will be a roll out to the rest of the county)

Primary Care cancer care.

When approved by the Project Board, this document will provide the baseline for the project. The ongoing viability of the project will be monitored against this and it will be referred to whenever a major decision is taken. This document will also be used at the completion of the project to measure whether it was managed successfully and delivered acceptable results.

2.2 Background

As the population ages and the incidence of cancer rises there is a greater need to transform cancer services for our population in Gloucestershire. Every year 3,400 more people in Gloucestershire receive a cancer diagnosis and there are an estimated {18,000} cancer survivors in the county. {Further data brief to be included to update estimation, with breakdown by cancer site}

Cancer diagnosis and treatment have improved in recent decades. In April 2014 statistics published by Cancer Research show significant progress in improving 10year survival rates in England and Wales.

50% of adults diagnosed with cancer in 2010-11 are predicted to survive 10 years or more. However, cancer is many diseases and survival rates varying significantly by cancer site and the gruelling mental and physical legacy of cancer treatment can remain for many years post treatment.

We know that the incidence of cancer is increasing our population ages and cancer incidence and prognosis can be effected by risk factors such as obesity and poor diet, lack of physical exercise and smoking.

These large-scale trends have led Macmillan Cancer Support to predict that number of people surviving cancer will double from 2010 to 2030. To meet this huge change in demand at a time of financial constraint will require a major shift in our thinking, allocation of resources and teamwork across the health, social care and voluntary sector.


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2.3 A Note on Terminology

Words are important in conveying our meaning and values.

We believe the national framed phrase of Living With and Beyond Cancer inclusively captures the people we wish to serve and positively recognises their diverse experiences and needs. We are therefore using living with and beyond cancer as our preferred terminology rather than ‘survivorship’.

Although Cancer Survivorship is also well established a comprehensive discussion with our local Patient Reference Group in October 2014 concluded that the term ‘survivorship’ can cause some issues and misunderstandings. Although we are choosing to use it less and it does still feature in some of our project plans but will give care to our future terminology.

2.4 Context

Nationally the lead policy document Improving Outcome a Strategy for Cancer (IOSC) (Department of Health 2011), summarises out the health priorities as follows:-

“People living with and beyond cancer often have specific support needs

which, if left unmet, can damage their long-term prognosis and ability to

lead an active and healthy life. These needs can include information about

treatment and care options, psychological support, access to advice on

financial assistance and support in self-managing their condition.”

IOSC acknowledges that although there have been significant improvements in support for people living with and beyond cancer, more needs to be done so that cancer survivors have the care and support they need to live as healthy a life as possible, for as long as possible. The strategy sets outcomes that we have adopted in our programme plan including:-

o reducing ill health associated with cancer treatment;

o reducing risks of recurrent cancer;

o reducing the proportion of people who report unmet physical or psychological support needs following cancer treatment;

o increasing the proportion of cancer survivors of working age who are

able to work who are in work

o increasing the proportion of cancer survivors who are able to live independently and self-manage their condition.


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The National Cancer Survivorship Initiative (NCSI) was established in 2007 as a partnership between the Department of Health, Macmillan Cancer Support and NHS Improvement. In 2010 the NCIS published their Vision Statement which incorporate 5 key shifts:

A cultural shift towards promoting recovery during and beyond treatment.

A care planning shift to fit individuals needs, risks and preferences

A shift to supported self management enabled by clinical assessment of risk.

A shift to tailored support to managing the consequences of treatment and possible recurrence

A shift to emphasising the importance of patient reported measure of experience and outcomes

Following this the NCSI have published a landmark report Living With and Beyond Cancer: Taking Action to Improve Outcomes (March 2013).

This pulls together the national programme’s substantial learning in building an improved intelligence and an evidence base of cancer survivorship interventions.

The recommendations of this guidance document form a substantial foundation for our programme of work.

Its recommendations are setting out across a 5 part framework for change.


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2.5 Definition of the Recovery Package

The Recovery Package is a series of key interventions which, when delivered together, can greatly improve outcomes for people living with and beyond cancer. Holistic Needs Assessment (HNA) - identifies the individual needs of the person affected by cancer and contributes to a consultation. The consultation can then be focused on the needs identified, a Care Plan can be developed and an appropriate referral can be made to services. The patient receives a copy of the care plan to enable self-management; further copies are stored in the medical records and can be sent to the GP. Treatment Summary - is compiled by the multidisciplinary team to provide important information for GPs, including possible treatment toxicities, information about side effects and/or consequences of treatment, signs and symptoms of a recurrence and any actions for the GP. It aims to inform GPs and other primary care professionals of any actions they need take and who to contact with any questions or concerns. The patient also receives a copy to improve understanding of their condition and to provide a summary to share with other professionals and those of their choice, eg for travel insurance purposes. A copy of the Treatment Summary in the case notes is also useful for medical staff if the patient is admitted in an emergency after primary treatment is complete. Cancer Care Review - is carried out by the GP practice within six months following a diagnosis of cancer, identifying patient concerns and giving information to enable self-management. It could be informed by the Holistic Needs Assessment.

Health and Wellbeing Clinics/Events – held at the end of primary treatment, are education events to give the person affected by cancer the holistic information they need to enable rehabilitation and self-management.

Risk Stratified Pathways – these are based on the cancer treatment received and personal circumstances of the individual allowing clinicians to identify which patients are suitable for self-management.

Gloucestershire CCG Cancer Programme

Gloucestershire Clinical Commissioning Group came into operation in April 2012 with responsibility for directly planning and funding the majority of health services in the county and collaborating with NHS England on the commissioning of primary care and specialised service.

Gloucestershire CCG has established active Clinical Programme Groups (CPG) to address the health and service priorities of our population. The Cancer CPG has agreed development areas as detailed in a Programme Brief (document currently being refreshed/updated) and summarised in the diagram below.


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Cancer Programme Overview

The Cancer CPG are also introducing an Outcomes Scorecard (see Appendix 1) that incorporates many key measures on cancer survivorship outcomes and the delivery of our Living With & Beyond Cancer programme delivery.

In addition Gloucestershire CCG’s overall 5-year of Joining up your care fundamentally guides the principles that we are applying to designing our approach for Living With & Beyond Cancer.


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2.6 Current Situation in Gloucestershire

Although change is required to better support cancer services in Gloucestershire, we are building on a foundation of some existing good support for cancer patients within the county. Significant new developments have progressed during 2014. Some of this work has been directly initiated by the CPG team and other by our partner organisations.

Some examples include:-

Primary Care: Since Spring 2014 Gloucestershire CCG have partnered with Macmillan Cancer Support to deliver a series of GP Cancer Master Classes which include information to promote early diagnosis and collaborative care between acute trust and primary care and a focus on supporting cancer patients following treatment.

Community Services: In February 2014 Gloucestershire CCG and Macmillan have agreed a development partnership to develop community-based survivorship team, with clinical leads commencing posts in September 2014.

Hospital Care: GHNHSFT has initiated a Patient Experience Quality Improvement Project that is implementing a range of service developments that integrate with this Living With and Beyond Cancer programme.

Hospital Care, Macmillan HNA Post: It is planned to offer people within the cancer pathways at GHNHSFT a Holistic Needs Assessment during at least two points; at discharge from active treatment and at another clinically significant point as determined by individual teams. The HNA implementation role will finish in September 2016.

Voluntary and Third Sector: people in Gloucestershire are already benefiting from support from services such as the specialised Village Agents and Maggie’s centre in Cheltenham, as well as many other organisations. We are also doing a lot of collaborative work with Macmillan.

In addition previous work was also undertaken by 3 Counties Clinical Network to map pathways of care rehabilitation, and some of this work will helpful in informing our new phase of service design work.

3 Project Definition

3.1 Overall Project & Programme Structure

The strategic programme and project strategy for the Gloucestershire Living with & Beyond Cancer work is shown in the following adapted driver diagram that incorporates the 5 drivers of the NCSI framework.


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To ensure people in

Gloucestershire can live well with &

beyond cancer

To enable patient and carers to be empowered

in their cancer

treatment, care and support

To achieve the best possible health & wellbeing

outcomes for people with a

cancer diagnosis

To develop Joined up

care across collaborating organisations

To allocate best use of

NHS resources to

meet increasing

demand and high quality

Information and support

from point of diagnosis

Promoting Recovery

Sustaining Recovery

Managing consequences of treatment

Supporting People with Active and advanced disease

Enhance GP Referral

Information

Introduce Library

Information Points

Focus & improve hospital patient

information

Holistic Needs Assessment &

Care Plans

Introduce Treatment Summaries

Introduce Risk Stratified Pathways

Hold more health & wellbeing events

Launch Community Cancer Care &

Education Programme

Map support groups & encourage development

Develop specialist village agent role

Improve signposting to healthy living, support

Primary Care Development

Better access to Fatigue Management

Adapted Driver Diagram linking project initiatives to strategy, objectives and aims

Education & Support


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3.2 Aims and objectives

The aim of the overall programme is to create sustainable and equitable services to ensure the best outcomes for the population of Gloucestershire and to enable people to live well with and beyond cancer. The programme will be supporting the huge cultural shift that is required to make this programme a success.

The objectives of the key stone projects of the programme are to:

3.3.1 Holistic Needs Assessment (HNA) and Care Plan (CP)

Aim: To re-launch the use of HNA/CP in Secondary Care with sustainability in the hospitals, community services and Primary Care. This will enable patients to have their wider health and wellbeing addressed and become actively involved in planning their ongoing care and support.

Objectives:

To offer all eligible patients within the Breast, Prostate & Colon Cancer Pathways a HNA/CP by [April 2016] and for 70% of eligible patients to have one offered at least twice in their pathway, with one of them being at the end of their primary treatment.

Holistic Needs Assessment & Care

Plans

Introduce End of Treatment Summaries

Introduce Risk Stratified Pathways

Launch Community Cancer Care &

Education Programme


Gloucestershire Living With & Beyond Cancer Programme

KEYSTONE PROJECTS 2015


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To offer all eligible patients within agreed other sites a HNA/CP by [April 2017] and for 70% of eligible patients to have one in place.

To improve communication and transfer of information from the HNA/CP, which will reduce the repetitiveness of questions being asked by different people at similar times

To ensure that all patients and health professionals know what their HNA/CP is and where to find it.

To improve Gloucestershire’s score on the Cancer Patient Experience Survey for the production of a Care Plan for each patient.

To ensure HNA/CP are a structured part of the care pathway for all tumour sites.

3.3.3 Treatment Summaries

Aim: To implement the use of end-of-primary Treatment Summaries within Gloucestershire initially for patients within the breast, prostate and colorectal cancer pathways and rolling out to all primary cancer sites. This will enable good joined-up care and communications.

Objectives:

To provide timely Treatment Summaries to the GP and patient using a locally agreed format for 100% of patients within the breast, prostate & colorectal cancer pathways at the end of each primary course of treatment by [April 2016] and thereafter continuing best practice communication by delivery of treatment summaries after each subsequent treatment block for relapse.

To ensure the Treatment Summaries meet the required communication standards to be developed and agreed by each site working group.

To ensure the TS details are appropriate for use by health professionals involved in the patient’s care and viewing by the patient themselves.

3.3.4 Risk Stratified Pathways

Aim: To ensure all patients completing treatment are assessed and assigned to an appropriate risk stratified follow-up pathway. This will enable appropriate low-risk patients to follow high-quality supported self-management.

Note: This project will overview the specification of site specific cancer pathways that include the components of the Recovery Package at the defined stages along with the management of risk stratification and follow up.

Objectives:

To allocate breast, prostate & colorectal patients completing treatment to an agreed clinically appropriate follow up pathway


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To ensure components of the Recovery Package are defined within clinical protocols, benefiting all patients and supporting low-risk patients to commence supported self-management.

To allocate proportions of patients in line with national Best Practice to the difficult levels of risk stratified pathways.

To ensure that robust and safe patient monitoring is in place.

To ensure good co-ordination with patient education programmes.

3.3.5 Community Cancer Care and Education Programme

Aim: The overall aim of the Macmillan Cancer Community Project is to

improve the health and wellbeing of people following cancer treatment.

With partnership funding we will establish an innovative community based service that will be developed and evaluated over a 2 year period. During the development phase of the project, only patients with breast, colorectal and prostate cancer will be included.

Objectives:

Develop and evaluate an innovative community based team of Allied Health Professionals supporting and educating breast, colorectal and prostate patients to self-manage their care within Gloucester city and North Cotswold communities

Deliver and evaluate a cancer specific education programme to health professionals who support people affected by cancer in the community

The desired outcomes of the community project are [outcomes to be matched into benefits section]:

Improved awareness of wider services available for people affected by breast, colorectal and prostate cancer

Improvement of quality of patient experience

Better informed and supported people who are affected by cancer

Access to voluntary/self-help and peer support

Better social integration

Improved self-management of the side effects of treatment

Improved self-management of the long term consequences of treatment

Prevention of unnecessary loss of function


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Enable the achievement of realistic goals

Better access to the appropriate services

Improved access to activity programmes

Improved well-being and self confidence

Less reliance/need for hospital based follow-up appointments

Improved integration of ‘survivorship’ into the Integrated Community Teams (ICTs)

Efficient use of Macmillan Community team and clinicians time

3.3.6 Primary Care Development

Aim: To raise the profile of cancer survivorship and ‘living with and beyond cancer’ issues amongst Gloucestershire GPs to enable supported self-management and raise awareness of ongoing implications of completing cancer treatment for their patients and families.

Objectives:

To ensure all GP cancer reviews are informed by treatment summaries (with holistic needs assessments informing the TS) thus following local Best Practice Guidance.

To ensure best practice cancer recovery and knowledge around symptom control is optimally supported by GP knowledge of community services and supports available for their patients.

To facilitate expansion of GP knowledge and awareness around cancer survivorship by attendance at GP Cancer Master Classes.

Further work required to ensure these objectives are SMART (Specific, Measurable, Achievable, Realistic and Timed.

3.3 Programme Scope

A defining characteristic of the Gloucestershire Living With & Beyond Cancer programme is that it co-ordinating a system wide change. The scope therefore covers a broad range of service providers and we are aiming to achieve a transformation that delivers joined up care and support from the patient’s perspectives.

3.3.1 Inclusions

Cancer Patient Groups


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Patients with a cancer diagnosis aged ≥ 18 years and Gloucestershire residents.

Cancer Sites

The first phases of the project cover Prostate, Breast and Colorectal Cancer. The rationale is that these pathways have:

o The highest volume of patients, therefore we can more rapidly make improvements for the greatest number of people.

o Implementation of risk stratification of follow-up on to high volume pathways allows for greater realisation of productivity benefits.

o National good practice developments focuses on these pathways, adopting and adapting this work will facilitate our implementation.

Other cancer sites are to be included in the scope of the project in subsequent phases.

Geographically

Patients registered with a GP in the Gloucestershire CCG area are generally in scope excluding phase one of the community- based services project (the pilot), which only applies to Gloucester City and North Cotswolds Localities’ patients. Phase two will include all localities.

(Further scoping clarification will cover Clinical Activities, Current Development Projects, National Guidance)

3.3.2 Exclusions – include Phase 1 and 2

Cancer Patient Groups

The development of services, care and support for Children, Teenagers and Young People are not included within the scope of this PID. However the needs of these groups are identified with in the Programme Brief for the Cancer Clinical Programme Group, and it is anticipated that a dedicated project theme will be initiated.

Cancer Sites – No cancer sites are to be excluded.

Geographically

tbc

Project Phases – Community Cancer Care & Education Programme

It is anticipated that the community-based care and education programme will be delivered in 2 phases:

Phase 1 – Test implementation of community cancer care and education in two geographical areas, Gloucester City and North Cotswolds, concentrating support on appropriate breast, colorectal and prostate cancer patients


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Phase 2 – After robust evaluation of the phase 1 project, full consideration will be given to extending the scope and size of the community based project into a phase 2

3.3.3 Constraints

For discussion 20/10/14 - A constraint is defined as anything that is restricting the project scope.


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3.4 Anticipated benefits

The project is expected to deliver a range of benefits that have been categorised as follows:-

BENEFITS: Patient Perspective Health Outcome & Quality Measures

– these have been aligned to Macmillan’s 9 Outcomes

I was diagnosed

early

To support earlier identification of recurrence, through reinforcing effective self-management and health awareness

I understand,

so I make good

decisions

To prevent people dying prematurely by reducing the risk of recurrence e.g. through care planning and supported direction to activity and good nutrition.

I get the

treatment and

care which are

best for my

cancer, and

my life

To enhance and sustain recovery from cancer by providing improved community based rehabilitation capacity, to include measures of mobility, nutrition, communication and psychological wellbeing.

To improve health by supporting the effective management or prevention of co-morbidities e.g. cardiovascular / diabetes, depression (cancer survivors can be at an increased risk level following treatment).

To support discharge/transfer of care processes following cancer treatment and good inter-professional working, to deliver good continuity of care in the most appropriate setting for the patient.

To implement risk stratified pathways so that patients can self-manage their care at home with support from the community teams.

I am treated To improve patient experience and feeling of wellbeing and


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with dignity

and respect

to promote a positive model for living with and beyond cancer.

I know what I can

do to help myself

and who else can

help me

To offer survivorship support that empowers informed patients to follow a self-management approach. To help people progress and develop their personal care plans by signposting to relevant support services.

Provide patients and employers with clear information on returning to work and finances

Those around

me are well

supported

To acknowledge holistic needs and link carers and families to supportive groups and services.

I can enjoy life

To improve care for people suffering anxiety and depression and offer psychosocial support to address the wider impact of cancer on people’s lives and relationships.

I feel part of

a community

and I’m

inspired to give

something back

To strengthen links to community resources to access to exercise and education resources etc and work in partnership to coordinate active information hub.

I want to die well

To ensure good co-working and interfaces with palliative care and end of life pathways.

To support principles of advanced care planning.

BENEFITS: Productivity

Reduction in follow-up appointments.

NHS Improving Quality’s Quality & Productivity Document on Stratified cancer pathways: redesigning services for those living with or beyond cancer (Sept 2013)


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estimates that cost savings of £214,000 per 100,000 population.

For Gloucestershire’s population this equates to £1.3 million.

Appropriate use of primary care resource

Extended community services will reduce primary care demand from some patient groups by increasing a patient’s ability to self-manage through enhancing recovery and healthy living support.

This will enable greater primary care co-management of cancer follow-up for low risk patients.

BENEFITS: Innovation

Adoption of national best practice.

Benefits for people in Gloucestershire of the guidance and recommendations from Living with & Beyond Cancer guidance.

Local innovation

Our proposed approach is to develop a community based development team within Gloucestershire’s Integrated Community Teams. This will support a person-led approach that supports wider health and social care needs rather than just a cancer service.

BENEFITS: Staff & Clinical Team

Collaboration & communications

New working models will improve communication, education and co-working across primary, secondary and community care – better for both patients and staff.

Patient & family relationships

Structured framework to care planning will help enhance communications with patients and carers and support shared decision making.


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Focussed time Clinical team members investing time in the most appropriate patients for their clinical contribution.

Involvement in improvement

Having a say in the development of patient care help gain a sense of staff satisfaction.

Others to consider adding / classifying:

3.5 Project success criteria

Improved Patient Experience Survey score compared to the 14/15 results

Increased number of patients on risk stratified pathways, resulting in a X% reduction in follow up appointments for Breast, Colon and Prostate Cancer

Implementation of the Recovery Package

Details of evaluation

Community project success

The Community Cancer Care Programme will aim to improve the health and wellbeing for people affected by breast, colorectal and prostate cancer in Gloucester City and North Cotswold communities, by providing:

- transitional care to optimise recovery

- empowering self-care support

- providing patient and family specific education

- improved links to community support and resources

- training and education to community based health professionals

An external company specialising in project evaluation will undertake full evaluation of the project.

3.6 Assumptions

Describe what assumptions we are making, an assumption is something that is taken for granted or accepted as true without proof.

3.7 Interdependencies


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The foundation projects detailed in this PID have many interfaces between themselves, with the wider developments of the Gloucestershire Living With & Beyond Cancer programme and the wider Cancer Programme.

The effective management of dependencies will be co-ordinated by the Gloucestershire Survivorship Steering Group.

3.8 Change control process

Any change in scope, budget or schedule will be requested by submitting a change request form to the Project Manager with details of the implication of the change in terms of costs or changes to deadlines as a result.

(Tolerances on costs & timings to be confirmed)

4 Project management approach

The Gloucestershire Strategic Forum is currently agreeing a Transformation Framework to enable consistent delivery of change project across the local health & social care system.

However it is anticipated that this will support this a NHS project management framework based on a flexible application of PRINCE2 methodology. The project will be led by the Project Board / Steering Group, supported by the Project Director and Project Manager.

A formal project management approach will be adopted to increase visibility of the work that needs to be undertaken and the decision making process. This means the project will be managed against a clear documented project plan; there will be a communications and involvement plan to ensure all stakeholders are kept up to date and a shared and open risk and issues log. The Project Board will meet and agree to review and sign off key deliverables and approve progression to the next stage of the project.

This project will have a beginning (Project Initiation), a middle (Delivery & Control) and an end (Formal Project Closure). However it is expected that our wider work for Living With & Beyond Cancer will be an ongoing programme of continuous improvement and possibility other projects for defined delivery.

The project delivery work will be undertaken through a number of workstreams that into the following work streams:-


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Cancer Site Focus for Engaging Clinical Teams

Redesigning the working approach of our cancer services needs to be done with in-depth involvement of the cancer teams concerned.

Project Teams are being set up to work on the Keystone Projects identified above. These Project Teams will have representatives from all relevant stakeholders, including GHNHSFT and CCG

Project Management

Design & Delivery

Communications & Involvement

Finance & Data

Commissioning

Holistic Needs

Assessments & Care Plans

Community Cancer Care & Education Programme

End of Treatment Summaries

Risk Stratified Pathways



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4.1 Stages

An approach is needed that ensures all stakeholders are fully aware of and agree to the principles and benefits of the new service configuration. All stakeholders must be fully engaged in the process, so concerns can be raised and addressed and the proposed service model reflects the latest clinical guidance and is acceptable to all.

The following staged approach will be used during the review:-

Time

Agreeing Joining Up Approach &

Project Initiation

Service Model Development

Design & Development

Implement, Test & Evaluate

Legacy Commissioning

& Project Closure

Oct 14 Jan 15 Apr 15 Jan 16 Jan17 Apr 17

Project Management Workstream

Design & Delivery Workstream

Communications & Involvement Workstream

Finance & Data Workstream

Commissioning Workstream


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5 Deliverables

Project management Design & Delivery Communications & Involvement

Finance & Data Commissioning

Overarching

PID Steering Group Minutes Risks & Issues Log Project Budget

Best Practice Model Joint Key Stakeholder launch

event (2nd

December)

2015/16 Commissioning intentions

Holistic Needs Assessment Care Plans

Project Plan Risk and Issues Log

tbc 2015/16 Commissioning intentions

Project Plan Local structure, format, and usage guidance.

Experience Based Design & Testing

2015/16 Commissioning intentions

Treatment Summaries


Super PLT Event 2015/16 Commissioning intentions



Standard Workgroup rapid design framework

Risk Stratified Pathway for each tumour site.

Design and test events by cancer site.

Joint acute/GP approach to pathway development

Local QIPP opportunity assessment.

Dashboards and reporting – how we monitor impact/activity

2015 – Phasing in of QIPP risk share proposal

Community Cancer Care & Education

Programme

Project Plan Risk and Issues Log Evaluation Plan

Mapping presentation of service provision

Stakeholder Engagement Events

Branding and Advertising

Project Budget Plan Macmillan Learning and

Development Grant Bids

Service Specification


Project Plan (joint with Early Diagnosis)

GP Education Masterclasses, incorporating survivorship

Education programme Best practice for Cancer

Care Review (Macmillan templates)

Care Pathway Development

Promoting Early Diagnosis Plan

GP input into Treatment Summaries

Macmillan Funding Bids Primary Care Offer

funding analysis

2015/16 Primary Care Offer Component


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6 Project organisation

6.1 Organisation chart

Cancer Clinical

Programme

Group

Macmillan

Survivorship

Project Board

Community

Cancer Care &

Education

Programme

Primary Care

Development

Holistic Needs

Assessments and

Care Plans

Treatment

Summaries and

Risk Stratified

Pathways

Gloucestershire

Survivorship

Steering Group

Prostate

Cancer

Breast

Cancer

Colorectal

Cancer

Working

Groups

Project

Teams

CCG

Governing Body

6.2 Gloucestershire Survivorship Steering Group The Gloucestershire Survivorship Steering Group will meet at set dates for project review and at any other exceptional times as determined by the Project Director, usually depending on the criticality of project progress. The Chair of the CPG will agree the Chair for the Gloucestershire Survivorship Steering Group. There will be minutes taken for all meetings. The minutes will record all the key decisions reached in meetings and any agreed action points. Minutes will be distributed to all interested parties within a week following each meeting.

6.3 Survivorship Project Board The Survivorship Project Board will meet at set dates for project review and at any other exceptional times as determined by the Project Director, usually depending on the criticality of project progress. The Chair of the CPG will agree the Chair for the Project Board. There will be minutes taken for all Project Board meetings. The minutes will record all the key decisions reached in meetings and any agreed action points. Minutes will be distributed to all interested parties within a week following each meeting.

6.4 Project Team The primary function of the Project Team is to undertake the operational activity required in order to achieve the success criteria of the project. The Project Team meets on a regular basis, as determined by the Project Manager. Individual meetings may be held


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according to circumstance and project management requirements. For each stage of the project all those connected to the project (including other team members brought in for specialised tasks) will work closely with all Project Team members on progressing the project’s work. They will be invited to Project Team meetings as relevant.

6.5 Working Group

The primary function of the Working Group is to work on specific areas of the project, i.e. a specific cancer tumour site, and progress the project in this area.

6.6 Patient Reference Group Gloucestershire Cancer CPG Patient Reference Group will be involved to ensure all key project products take patient, carer and public views into consideration. The Patient Reference Group will meet to consider key products, as scheduled within the Project Plan.


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Keystone Sponsor Clinical Leads Project Leads

Joining-up Programme

Charles Buckley Sadaf Haque

Kathryn Hall (PD)

Hayley Payne (PM)

Holistic Needs Assessment

Care Plans

Sue Savory Alice Kennedy Alice Kennedy

Sian Middleton Sian Middleton Alice Kennedy

Treatment Summaries

Neil Borley Sian Middleton &

Sadaf Haque

Anthony Walsh (Project Director)

&

TBC


Neil Borley

Prostate – Jonathon Eaton & Lucinda Poulton

Breast – Clare Fowler, Rachel Owers & Sue Scarrott

Colorectal - Neil Borley/Emma Mitchell & Michele Silavant

Anthony Walsh (Project Director)

&

TBC

Community Survivorship

Service & Education

Programme

Annie MacCallum Sara Mathewson &

Nikki Hawkins Hayley Payne


Charles Buckley Sadaf Haque Hayley Payne


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7 Project communication

7.1 Introduction It is important that views of key stakeholders are considered alongside the clinical evidence, local data and financial information in reviewing the service model. Stakeholders should own the outcome of the review. Whilst different stakeholder may have different priorities, there should be shared agreement on the project benefits and an agreement to respect differences to allow them to work together to drive through the model into future practice. It is important stakeholders feel they are involved in the process and they understand and are kept up to date on the progress of the project. All communications will be scheduled into the project plan and the Project Manager will have responsibility for working with members of the Project Team to ensure communication task are completed on-time.

7.2 Stakeholder map

Stakeholders

Gloucestershire Hospitals NHS Foundation

Trust (GHNHSFT)

Medical Director

Clinical Directors

Consultant Oncologists

Consultant Breast Surgeons

Consultant Urology Surgeons

Consultant Colorectal Surgeons

Consultant Upper GI Surgeons

Palliative Care Consultants

Consultant Clinical Psychologist

General Manager Cancer Services

Lead Breast CNS

Lead Prostate CNS

Lead Colorectal CNS

Head of Cancer and Palliative Care Nursing

Lymphoedema Nurse Manager

Trust Chaplin

Radiologists

Head of IT Shared Services

MDT Co-ordinator

Macmillan

Development Manager

Rehabilitation/Recovery Package Project

Lead

Associate Development Manager

Learning & Development Manager

Macmillan National Medical Advisor

Gloucestershire Care

Services NHS Trust (GCS)

Head of Specialist Services

Service Leads - ICTs

Gloucestershire Rural

Community Council

Specialist Village Agents

Primary Care

GPs

Practice Nurses

Dentists

Patients

Lay Champions

Patient Reps

Voluntary Sector/Local Charities

Support Groups incl. Maggie’s and Charlie’s

Tumour Specific Charities incl.

Prostate Cancer UK, Breast Cancer Care, Colon Cancer UK,

Pelvic Radiation Disease Association

Carers Gloucestershire

Prostate Cancer Support Group

Penny Brohn Cancer Care

County Council/District

Councils

Public Health

Community Partnerships

Managers

Community Engagement

Managers

Healthy Communities

Officers

Gloucestershire CCG

Senior Commissioning Managers

Survivorship Leads

Clinical Leads

Locality Managers

Project Manager

Patient Experience Department

Out of County – National &

Regional

Health Care Teams from other

localities e.g. Bristol and other

Survivorship Leads

National Site Specific Groups

(SSGs)

The map does not include all the details, they are in an excel spreadsheet which is a separate document as it will need constantly updating.

The excel spreadsheet needs to include the names and contact details of all the stakeholders and categories them in terms of importance and how they should be handled. See the separate Stakeholder map and analysis template for more details.


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7.3 Stakeholder involvement

An outline of the communications plan to be included in this document.

Communication & Involvement e.g.

Sent project briefing paper (x3)

Receive a copy of the project newsletter (x3)

Presentations at Health Overview and Scrutiny Committees / inivitations to stakeholder workshops (as agreed if necessary)

Patient, Carer and Public The role of patient, carer and public stakeholders are to ensure the views of the public, patients and carers are taken into consideration in developing the service model and site criteria. Communication & Involvement

The User/Lay Reference Group will have the opportunity to feed their views into the service model

Invited to workshop to discuss involvement

Invited to attend user/lay reference group

Invited to provide written feedback on key documents

Invited to the stakeholder event

Receive a copies of the project newsletter

Represented on the project board

Part of the independent panel process

8 Project budget and timescales

8.1 Project budget To agree approach to co-ordinate of project budget approaches.


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8.2 Key milestones

8.3 Holistic Needs Assessment and Care Plans Timeline

Gather formal feedback from staff and patients

Attendance of team members at HNA training

Sites agree use of HNA Tool

Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sept 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16

Patient Information written and agreed

May 16 June 16 July 16 Aug 16 Sept 16

Basic signposting materials in place

HNA being used regularly at least once during treatment pathway


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8.4 Treatment Summaries Timeline

8.5 Risk Stratified Pathways Timeline

Feedback from GPs re. how useful it is and format

Format of TS agreed

Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sept 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16

Begin testing in one or two tumour sites

May 16 June 16 July 16 Aug 16

Feedback received from staff re. format

Start to use TS in other tumour sites and incorporate into pathways

Sept 16

Current pathway mapped

Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sept 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 June 16

Final pathway mapped

Implementation (phased)

July 16 Aug 16 Sept 16


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8.6 Community-Based Cancer Survivorship and Education Project Timeline

8.7 Primary Care Development Timeline

Super PLT on Survivorship

Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sept 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 June 16 July 16 Aug 16 Sept 16

Survivorship embedded into GP Educational Masterclasses

Draft Service Specification written

Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sept 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 June 16 July 16 Aug 16 Sept 16

Service Specification signed off

Comms Strategy written and agreed

New team recruited

Service goes live

Go out to tender for evaluation of service

Service continually evaluated


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9 Risk and Issues

9.1 Risk, Issues and Change Log A risk is something which hasn’t happened yet which can be mitigated. The potential risks to the project will be identified as part of an initial consultation meeting with stakeholders. It is expected that the Project Board, Project Team and other stakeholders can add any concerns by emailing or phoning the Project Manager who will include these onto the risk log. Each risk will be allocated a risk owner. The Project Manager is responsible for actively ensuring risks are being managed. The Project Board and Project Team will have responsibility for reviewing risks and where appropriate, putting in place actions to mitigate these. A more detailed risk and issues log is available from the project manager and will be updated after each project team meeting.

Issues are managed by recording them in the Issues log, allocating an owner and by the

Project Board and Project Team reviewing them regularly.

The Change log is where all changes and resulting actions are held as described in section 3.7 Change control process of this template.

For more information see 13. Risk, Issues and Change Log template.

10 References & web addresses

http://www.ncsi.org.uk/wp-content/uploads/Stratified-cancer-pathways-12_0020.pdf?utm_source=NewZapp&utm_medium=email&utm_campaign=Eyes%20on%20Evidence%20email%20campaign





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Appendix 1 Project Management Products

Project Plan

Purpose To provide sufficient detail of the project schedule with key dates, milestones and dependencies to establish start and end dates for project products and activities. This document should help to ensure visibility of all tasks to all stakeholders as well minimising risk and ensuring the project reaches the end date on time.

Composition Gantt Chart

Derivation Project team input into initial draft, additional information fed by Project Board.

Format Microsoft Project

Allocated to Project Manager

Quality Criteria Does the document correctly represent the project?

Is it clear when the project activities will occur?

Are all dependencies clearly marked?

Does the plan clearly show who is responsible for each activity?

Have all allocated resources confirmed the estimates against their activities?

Quality Assessment Method

Review against Project Initiation Document to validate that planned activities will meet project objectives. Reviewed monthly.

To be assessed by?

Project Assurance Manager

Sign-off Project Board sign-off baseline project plan and tolerance. The Project Board will need to agree any major changes to the initial baseline plan.

Risk and Issues Log

Purpose To provide a means of documenting identifying and managing risks and issues so that they can be communicated, understood by stakeholders and agreed if action needs to be taken to avoid a risk becoming an issue.

Composition Number, risk description, owner, score, date raised, action taken and resolution date as applicable.

Derivation Initial project risks identified by Project Director and Project Manager. Additional risks and issues to be identified by stakeholders and submitted to the Project Manager.

Format Microsoft Excel


Quality Criteria Does the document clearly define and rank the risks with the appropriate owners and where appropriate resolution dates?

Does the document provide a clear and unambiguous narrative as to the perceived problem (risk) so misunderstanding is minimised wherever possible?

Does the document clearly show the transition of a risk to an issue where appropriate?


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Are there clearly defined risk responses and actions?


The document will be formally updated on a fortnightly basis and circulated to Project Board members. The Project Board and Project Team should actively input in to the development and up keep of the log.

To be assessed by?


Sign-off Project Director

Project Board Terms of Reference

Purpose To ensure all attendees are clear on the purpose of meetings and decision making process

Composition The terms of reference should define who is on the Project Board, the decision making process, the outcomes/output that the Project Board is responsible for and communication channels with other groups and organisations.

Derivation Information in Project Initiation Document re project organisation

Format Microsoft Word


Quality Criteria All roles included, with clear descriptions of their roles and responsibilities


Approval by Project Board members

To be assessed by?


Sign-off Project Board


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Appendix 2 Project Quality Control and Configuration Management

Project quality control

In the ‘Project Management Products’ section of the PID (see section 6.1), for each product there is a description of the quality criteria; quality assessment method; who will assess the product and who will sign it off. A Quality Plan will be completed during the life of the project which will describe all the products produced at each stage, who assessed and signed them off and when.

Configuration management

A nominated member of the project team will hold the final version of all documents that are “project products”, saved on the Cancer CPG folders of Gloucestershire CCGs file structure.

All team members will be responsible for agreeing and the using consistent project documentation across the project areas.

Consistent use of author, date and version control information.

Project Manager will be responsible for ensuring processes for circulation, consultation and collation of feedback is consistent across the project.


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Appendix 3 Roles and Responsibilities

We will need to define the roles and responsibilities involved in the project. The roles will relate to the organisational structure and the work streams. They may include Project Board Chair; Project Director; Project Manager; Service Redesign Lead; Project Support Officer; Finance Support; External Clinical Expert; Workforce and Organisational Development Lead; Data Manager, IM&T Lead, Project Assurance Manager; Patient and Public Involvement Manager; Clinical Leaders, Lay/User Reference Group Representative; Link Representative; Commissioning Manager. See below for two examples:-

Project Sponsor

Role and Objectives:

Responsibilities: Overall responsibility for the success of the projects within the work programme.

Indicators of Success:

Scope of Authority:

Interfaces:

Project Lead


Responsibilities:


Scope of Authority:

Interfaces:

Clinical Lead


Responsibilities:


Scope of Authority:

Interfaces:


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Appendix X

Format as a list and add to appendix with examples of TS and HNAs

Suggested inclusions are: background information (co-morbidities, family history, new or recurrent cancer, tumour type and histology), staging, summary of treatment received and performance status at the end of treatment, side effects anticipated long-term, potential late effects of treatment, follow-up care including outpatient appointments, blood tests and imaging, actions for the GP eg ‘look out for…’, advice as to when to call your GP with particular signs and symptoms, summary from the HNA identified needs or concerns eg genetic risk, emotional or mental health, personal relationships, fertility, financial advice and summary of referrals provided to eg dietician, smoking cessation counsellor, OT, genetic counsellor, psychiatrist/ psychologist, social worker, fertility specialist. Oncology Team member contacts are also useful details for the TS.