BART’S HEALTH CANCER CARE @ HOME ( BHCC@H ) Dr Mariya Rashid Foundation Year One Doctor Dr Samir Agrawal Consultant Haemato-Oncologust

remote Patient Monitoring Programme (rPMP) Initiated in 2015 Delivers specialised cancer care remotely

BACKGROUND Poor performance of London cancer services in National Cancer Patient Experience Survey (NCPES) Patient demand Workload management

National Cancer Patient Experience Survey Several factors had a negative impact on patient experience: Overcrowded waiting rooms Long clinic waiting times Waiting for blood tests and pharmacy. Commonest suggestion:“reduce waiting times”. Survey showed positive response to the idea of remote monitoring.

BHCC@H - OBJECTIVES Primary objective: Secondary Outcomes: Improve patients’ quality of life – minimising visits – ongoing specialist care Secondary Outcomes: Minimise the stress of travel, costs and delays associated with hospital visits Empower patients direct access to blood results / letters A major goal of government policy for health care is allowing patients a choice in the delivery of their care, with a focus on bringing care in to the community. 5

Eligible patients identified inclinic PATIENT ENROLMENT Pre enrolment Eligible patients identified inclinic “Blood pack” sent to patient, includes: Questionnaire (pre-paid envelope) OR, patients can input their data online BHCC@H admin team collate results and book appointment Post enrolment/ Pre appointment ADD slide with the Royal Mail samples box to show alternative approach, where testing is done at the centre?? Remote consultation – telephone / video Discuss responses and review blood test results Agree Follow-up Instant access to results and letters via the BHCC@H portal Appointment 6

BART’S HEALTH CANCER CARE @ HOME NOT easy to read of follow BHCC@H Portal Generates an ‘End of Treatment’ summary for every patient; a requirement of London Cancer which is currently unmet. Allows high quality Audits to be carried out. Amalgamates blood results and a consultation letter to generate regular patient reports which are available to GP’s and bridges gaps between primary and secondary care. Allows direct interaction with patient’s through the ‘ask a question’ function reducing the number of non-urgent calls to CNS’s, the hotline and the day unit. 7

BART’S HEALTH CANCER CARE @ HOME NOT easy to read of follow BHCC@H Portal Generates an ‘End of Treatment’ summary for every patient; a requirement of London Cancer which is currently unmet. Allows high quality Audits to be carried out. Amalgamates blood results and a consultation letter to generate regular patient reports which are available to GP’s and bridges gaps between primary and secondary care. Allows direct interaction with patient’s through the ‘ask a question’ function reducing the number of non-urgent calls to CNS’s, the hotline and the day unit. 8

Patient Survey 50 patients were surveyed 64% response rate

Patient Survey For a single hospital clinic at Barts:   For a single hospital clinic at Barts: Do you take time off work ? Does this affect you financially ? Yes/No/How much ? Travel - costs ? Time taken ? Waiting time to see the doctor ? Did someone come with you? Did they take time off work ? what costs did they incur?

Patient Survey For rPMP appointments: How many appointments have you had in 12 months? Costs per rPMP appointment? Was the service easy to use? Yes/No How has rPMP helped you? What are the drawbacks for you? Rate the service? Suggested Improvements?

PATIENT IMPACT Hospital Clinic rPMP Time off work (days)* 2 (1 – 3) Loss of income Up to £475 Travel costs# £30 (0 – 79) Travel times 60 – 240 min Companion 34% Travel costs £40 (0 – 50) Waiting times 60 (30 – 210) min 12.5% of patients reported stress and anxiety of coming to hospital /sitting next unwell patients *: most patients retired #: 53% had travel costs ; 15% used hospital transport 12

PATIENT IMPACT Hospital Clinic rPMP Time off work (days)* 2 (1 – 3) Nil Loss of income Up to £475 Travel costs# £30 (0 – 79) Travel times 60 – 240 min Companion 34% - Travel costs £40 (0 – 50) Waiting times 60 (30 – 210) min Nil** Easy to use Yes – 88% Overall rating (1 – 10) 10 (1 – 10) Hospital Clinic rPMP Time off work (days)* 2 (1 – 3) Nil Loss of income Up to £475 Travel costs# £30 (0 – 79) £5 Travel times 60 – 240 min Companion 34% - Travel costs £40 (0 – 50) Waiting times 60 (30 – 210) min Nil** Easy to use Yes – 88% Overall rating (1 – 10) 10 (1 – 10)   13

PATIENT BENEFITS OF BHCC@H 16% of patients were at work, in transit, shopping, abroad, waiting at another hospital appointment Convenient “[Saved] arranging childcare”.   “Very useful as I am a carer for my disabled wife” Flexible “Easier to fit into work, able to have blood tests done nearer to home, saves time” Patient centred and Empowering  “Makes me feel more involved in my illness” Accessible  “When I logged on to the system you could see all blood results from the last ten years”

PATIENT DRAWBACKS OF BHCC@H Lack of face to face consultation and physician examination  “I would like to retain the reassurance that can only come from personal consultation” Admin and system errors “It would help to receive blood forms a little earlier” Not suitable for all patients  “I do not hear so well so need someone with me for the telephone appointment”

Summary: BHCC@H vs Clinic Decreases Travel – Time and Costs (patient / carer) No loss of income (patient / carer) No waiting time ! Ease to use – overwhelmingly positive experience [advantages to the NHS - service delivery / resources]

What I Have I Learnt ? Patients are not dependent on the hospital Patients are more accepting of change vs HCP The current clinic model doesn’t make sense Regular clinic visits for well patients ?? Workload vs Resource ? Are patients able to report when they are unwell ? Blood results are in our CRS, any issues (clinical or lab values) are highlighted before they get to clinic/Day Unit, reduces trips for patients and potential drug wastage, frees up Day unit and clinic space 17

FUTURE DIRECTION Patients on long-term oral chemotherapy Ibrutinib, Idelalisib, Venetoclax… Remote chemo pre-assessments FCR + other chemo regimens In fact, almost anything… Chemo pre-assessments are essential, but currently inefficient, requiring an extra trip to Barts for many patients and/or chasing of bloods done elsewhere. A suggestion: for certain diseases, patients who are well, have had TWO cycles and are responding, they could have their cycle 3 chemo pre-assessment remotely. 18