Milica Zina Bojin – United Lincolnshire Hospitals NHS Trust

According to reports, the upcoming NHS People Plan will include ‘radical’ proposals to allow nurses to perform surgical procedures to ease the burden on under-pressure consultants. Under the new plan, aspirational nurses will be trained to become Surgical Care Practitioners, qualifying them to carry out a range of surgical tasks. It’s a positive step forward for our profession. But it’s by no means the only way that nurses can play a role in transforming acute services. In fact, nurse-led transformation is already happening without the need for two-year training. My experiences in helping redesign the prostate cancer pathway at United Lincolnshire Hospitals (ULH) NHS Trust demonstrate just how nurses can lead change and make a difference to patient care. All that’s required is a clear need, a good business case and plenty of determination.

I’ve been a nurse consultant (urology) at UHL since 2015 and have always believed that service development and improvement is a fundamental part of the role. Good examples include the development of both our emergency urology and local cancer guidelines – projects in which I was heavily involved. I also oversee the professional development of our urology team, especially nurses. My overarching objective is to ensure we provide a high quality service offering for patients. A key aspect of this is making sure that any initiatives that might improve our pathways are considered, developed and, where viable, applied. In that sense, those two main components of my role – professional development and service improvement – go hand-in-hand; pathway redesign can not only improve the patient experience, it presents great development opportunities for staff. Two recent UHL projects in urology perfectly illustrate the point.

Nurse-led telephone triage

In February 2018, UHL began exploring the possibility of introducing a nurse-led telephone triage system to the prostate cancer service. The exercise was prompted by a Cancer Alliance call for ideas to improve the pathway. The rationale for telephone triage appeared obvious; our existing pathway was protracted, often requiring two-week-wait (TWW) patients to go back and forth to the hospital for investigations while we determined the right course of action. At times, the patient experience could be poor. We needed to improve it.

Having suggested the concept of nurse-led triage, I worked closely with our business unit, the cancer department and Cancer Alliance to map the project and build a business case to show it could transform the pathway. That business case was subsequently approved by the trust. Today, the system – which sees our triage nurse proactively arrange all required investigations for TWW patients – is part of standard practice. We were grateful to receive financial support from the Cancer Alliance who funded a long-term triage nurse.

The triage system ensures patients have completed all of their investigations – whether that’s an additional PSA, MRI, bone scan, CT or prostate biopsy – prior to their first appointment with a consultant. As a consequence, the consultant has all the results (s)he needs to make timely and appropriate clinical decisions. The approach has made a huge difference, accelerating the referral pathway, removing avoidable delays and ultimately expediting diagnosis. In most cases, the pathway has been shortened by a good two weeks. In the immediate aftermath of the system’s introduction, we saw improvements in our 62-day cancer pathway for three consecutive months. It’s a great example of how nursing innovation can transform patient care.

Redesigning the biopsy pathway

But the journey to service improvement is never-ending. Having made good gains with telephone triage, we shifted our focus onto improving the pathway for patients requiring transperineal biopsy. Our approach was again driven by a pain point I’d identified when auditing the pathway: since transperineal biopsies were being conducted in theatre, there was often a six week wait for the procedure. Additionally, the hospital was doing many TRUS biopsies that were coming back negative – and the majority of these patients would then go to theatre for a template biopsy to give clinicians the reassurance to discharge or step them down from the pathway. The whole process was slow, inefficient and distressing for patients.

Having presented my findings at one of our audit meetings, a Trust partner told me about a new technique that was helping hospitals conduct transperineal biopsies under local anaesthetic in outpatient settings – thereby facilitating pathway change. In many of these trusts, the procedure – LATP – is carried out by trained nurses, relieving the burden from urological consultants and freeing them to focus on diagnosed patients.

The benefits of LATP were self-evident: efficiencies in the pathway would save us time and money, whilst moving the procedure into an outpatient setting would help the urology team maximise precious theatre time. Evidence indicates that LATP is a good alternative to traditional TRUS biopsies, which can increase the risk of infection and yield inaccuracies in identifying cancer cells. LATP isn’t a practical option for everyone – but shifting to it, where possible, seemed like a good idea.

Having recognised the opportunity, I again worked with key stakeholders in the trust to build the business case. They immediately saw the transformative potential and supported me in driving it through.

In November 2018 I began learning how to use PrecisionPoint, the pioneering freehand technology that’s opening the door to LATP. The training, supported by SE London Accountable Cancer Network, saw me journey to Guy’s and St Thomas’ Hospital every week for three months to observe, learn and practice under the tutelage of Jonah Rusere, the Network’s Advanced Nurse Practitioner.  Subsequently, one of our urology consultants gave me his patient list, enabling me to carry out the procedure in theatre, under supervision. I then graduated to the outpatient setting, performing the procedure under local anaesthetic, with the supervision of expert practitioners. I’m now fully authorised to conduct LATP on my own. We run 4 lists a week in outpatients.

The outcomes to date have been encouraging. Beyond the practical benefits of redesigning the pathway, the clinical gains have been good. An audit of patients undergoing prostate biopsy between May and August 2019, showed that targeted and systematic LATP biopsies picked up more clinical significant disease than TRUS – and also allowed us to discharge almost 60% of patients with negative biopsies. The approach has enhanced the patient experience too, with patients no longer stuck in a repeat cycle of invasive biopsies before they’re diagnosed or discharged. It’s a win-win for everyone.

Nurse-led transformation

The triage and LATP projects at UHL are good examples of nurse-led service transformation – and, while specific to the NHS, they’re a vindication of any approach internationally that advocates nurses playing a greater role in optimising patient pathways.

With the World Health Organisation estimating that the world will be short of approximately 18 million health workers by 2030 – a fifth of the workforce needed to keep healthcare systems going – it is important that healthcare ecosystems make the most of the valuable resources that we have.

Changing existing processes and ingrained ways of thinking isn’t easy. Neither is achieving success. It requires perseverance to overcome potential resistance, and hard work to develop the evidence-base to persuade others of the need for change. However, with a good business case, a good understanding of your service and patient needs, and good support from core stakeholders, it’s possible to make a huge difference for patients. Ultimately, as nurses, that’s all we’re here to do.

Submitted by Milica Zina Bojin, Nurse Consultant Urology at United Lincolnshire Hospitals NHS Trust.