Neuro-oncology: cancer rehab really matters

A new intensive rehab team at St Bartholomew’s Hospital is helping neuro-oncology patients to recover – and saving the NHS £20,000 a month. Gill Hitchcock reports. 

Rebab is critical

From a bed in the cancer wing at St Bartholomew’s Hospital, in the City of London, Danielle Chinnon talks about her struggle with chemotherapy and her joy in the physiotherapy which is helping her walk again. ‘It wasn’t until I was taken to the gym and used the parallel bars that I appreciated just how much work I had to do,’ says Danielle, who was admitted seven weeks earlier with spinal cord compression caused by a tumour.

‘I tried to walk and thought, gosh. But I have come a long way under the supervision of Jo and her team. They set challenges, which are certainly not easy, but I am the sort of person who says let’s do it again.’

Jo Wade, a highly specialist neuro-oncology physiotherapist, is able to treat Danielle thanks to funding from Macmillan Cancer Support for a two-year trial service of intensive rehabilitation. 

Since July 2017, the money has paid for Jo’s band 7 post, plus a band 7 occupational therapist and a highly specialist therapy assistant. They are managed by physiotherapist Lindsay Farthing, the hospital’s clinical lead for oncology therapies.

As Lindsay says, delivering therapy is not easy. ‘People are having cancer treatment which is knocking them for six, so you are juggling the rehabilitation against a potentially progressive disease and the side effects of treatment.’

A report on the first six months of the service shows positive results, however. Using a variety of outcome measures, the service has demonstrated an improvement in patients’ functional independence and a reduction in neurological impairment.

Better life, lower costs

As most patients are discharged with a higher functional level, they require less social support and care in the community, the report says. This can mean a better quality of life for the person and significantly reduced care costs. 

A case study in the document looks at a patient with a new diagnosis of lung cancer and metastatic spinal cord compression. It says that by improving his function and reducing his dependency, the service is saving more than £25,500 a year in community care costs. 

For Barts, as the hospital is known, the financial benefits are considerable too. Based on a reduction in length of stay for complex oncology spine and brain patients, the service is saving the hospital in excess of £20,000 per month.

More people are surviving cancer and Lindsay says data suggests that many of these are living with neurological impairments caused by the disease and would benefit from neuro-rehabilitation. Indeed, the National Institute for Health and Care Excellence’s gold standard is that cancer patients should be able to access rehabilitation at all stages of their disease – and at end of life.

An overstretched health service seems to be struggling to make this happen, however. At Barts, there is a shortage of rehabilitation beds for this patient group and, as Lindsay points out: ‘This is not just a problem for us, it’s a national problem.

‘There are a limited number of rehab beds for any neurological condition, but people with a palliative diagnosis are often excluded from ongoing inpatient rehabilitation. And, as we know, a palliative diagnosis does not necessarily mean that people do not have rehab goals.’

Against this backdrop, in 2016 Lindsay decided to apply to cancer charity Macmillan to fund specialist staff who would provide intensive neuro-oncology rehabilitation, an initiative the trust was happy to back. 

‘We had worked with Macmillan before, but what drove me to put in this bid was the lack of opportunity for this patient cohort and the life-changing impairments they faced, as well as the cancer diagnosis,’ she says.

Fortunately, in January 2017, she learned that she had been successful. Since the service started 12 months ago, Jo and her team have dealt with a caseload of approximately five inpatients at any one time. This allows them to treat people twice daily. Typically, they spend an hour and a half per day with each patient from Monday to Friday. 

New challenges

The team has other responsibilities too. ‘Our role might be supporting the community teams in delivering this more specialist care,’ Jo explains. ‘The hospital has patients who live in a range of London boroughs, each with a slightly different rehab team. Some don’t offer neuro rehab at all. 

‘So if there are any gaps in their knowledge, or their skills, or they are not sure how to manage these patients, we can provide the right type of help.

‘Another part of our role is seeing the patients home and joining up with the community therapy teams. This personal handover includes providing information about what we have been doing with the patients in the hospital, which community therapists have found invaluable.’

Despite the many positive effects, there are challenges facing the service. For instance, there are times when patients face a wait because the neuro-oncology rehab team’s caseload is full.

Discharging patients can be problematic too. A major hurdle emerges if a patient’s home is unsuitable for their return, now with a disability. They might live in an upstairs flat with no lift or wheelchair access, or in a shared house with other residents who are not family. ‘Then re-housing becomes an issue,’ says Lindsay. 

‘Obviously the social work or discharge teams try to come up with a solution, but it can take months.’

One way the neuro-oncology team helps is by recognising a housing issue early on and taking on a key worker role. This means engaging with external providers to devise a solution before the patient is ready for discharge. 

‘As that key worker, you can be on top of it, chase people and and make sure patients are home as quickly as possible,’ says Jo.

Has the service lived up to expectations? ‘It has probably exceeded them,’ says Jo. ‘We’ve shown improvements across the board. Functional outcomes have improved, patient experience is better and the financial side of things as well, not least because we have made significant cost savings by reducing length of stay.’

The next hurdle is to ensure the sustainability of the three posts. This is down to Lindsay, who is already preparing a business case to the trust, Barts Health, to secure long-term investment.

Easily replicated

Interest in the service seems to be growing. In July, members of the team gave a poster presentation about their work at the British Neuro-Oncology Society’s annual conference. This month, they will do similarly at the European Cancer Rehabilitation and Survivorship Symposium 2018.

Perhaps one of the most significant aspects of the service is that it could be replicated across other acute cancer sites. It currently operates across four acute cancer wards at Barts, with outreach to other wards. Yes, it has required three new posts, but no other additional resources, such as beds or equipment. 

And it’s in line with NHS England’s commissioning guidance for rehabilitation, which says: ‘It is increasingly acknowledged that effective rehabilitation delivers better outcomes and improved quality of life and has the potential to reduce health inequalities and make significant cost savings .’

Meanwhile, Danielle Chinnon is awaiting the outcome of an afternoon case conference about her future care. Whether she can be discharged back to her Essex home remains in the balance, but she is sure that her ability to walk again is thanks to the neuro-oncology team. 

‘The rehabilitation is absolutely marvellous,’ Danielle says. ‘It is probably the highlight of my day. I miss them at the weekend.’ 

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  • Gill Hitchcock

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