Referral Guidance for Cancer Psychological Support Services

For approvals and version control see Document Management Record on page 9

AngCN-CCG-PS46

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Approved and Published: December 2011

AngCN-CCG-PS46

Referral Guidance for Cancer Psychological Support Services

Anglia Cancer Network

1 INTRODUCTION These Guidelines are intended to provide clear criteria for referring patients for Psychological support based on the NICE Guidelines for Improving Supportive and Palliative Care for Adults with Cancer (IOG 2004). The referral pathway reflects the process described in the Four Level Model of Psychological Support advocated in the IOG. Details and evidence for this model can be found in the IOG. However since its publication initiatives regarding End of Life Care and Survivorship have emphasised even further the importance of integrating psychological support at its various levels into cancer care and highlights the relevance of assessing psychological needs as an ongoing process with particular attention at key stages of the cancer journey as described later. Survivorship within the context of psychological support is regarded as beginning from diagnosis onwards and embraces the concept that existential well being throughout the cancer journey is fundamental to the well being of patients and underpins their ability to adjust to different stages and phases of cancer. In addition the end of treatment assessment should embrace the Survivorship Agenda. The Holistic Assessment process is implicit within this model and supports its implementation. Therefore this document should be used in conjunction with Holistic Assessment Guidelines and the Survivorship Initiative.

2 MODEL OF PSYCHOLOGICAL SUPPORT 2.1 Four level model

The following table shows the four levels of intervention as set out in the NICE Improving Supportive and Palliative Care for Adults with Cancer (2004) (IOG). Level 1

Group All Health and social care professionals

Assessment Recognition of psychological needs

2

Health and social care professionals with additional expertise Trained and accredited professionals

Screening for psychological distress Assessment for psychological distress and diagnosis of some psycho pathology

3

Intervention Effective information giving, compassionate communication and general psychological support Psychological techniques such as problem solving Counselling and specific psychological interventions, such as anxiety management, cognitive behavioural therapy, delivered to an explicit theoretical frame work

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Referral Guidance for Cancer Psychological Support Services

Mental Health Specialists

4

Anglia Cancer Network

Diagnosis of psycho pathology

Specialist psychological and psychiatric interventions such as psychotherapy, including cognitive behavioural therapy

2.2 Level 2 support and assessment

Professionals providing level 2 support should be able to screen for psychological distress, guided by the Holistic Assessment Process. In order to ensure and develop competence in screening and assessing and in order to comply with Peer Review Measures those working at level two should have undergone appropriate training e.g. the Salisbury Model or one based upon it. Holistic Assessment may include the use of a tool such as the Distress Thermometer. It should be noted, however, that the Distress Thermometer, along with other such tools, are useful, particularly for initiating discussion, but are not a definitive measure of distress. Level 2 Support also includes some simple interventions to alleviate anxiety. This, along with the empathic support which informs the assessment process, may lead to some resolution of concerns and the ability to cope on a day to day basis If the concerns identified:a) Do not fall into the category of level 2 simple interventions and/or b) Level 2 interventions have not been of significant value and/or c) Referral to Complementary Therapies,(if available), the Chaplaincy, Support Groups, Palliative Care is not appropriate or sufficient d) It is apparent that there is a need for crisis intervention Then the next step is referral to level 3 or 4 psychological intervention or Psychiatric and Mental Health Services depending on the assessment findings. 2.3 Key stages

It is suggested in the Model that the assessments are made at key points in the patient’s pathway including:    

Time of diagnosis During treatment As treatment ends (this stage links with the Survivorship Programme) At the time of recurrence At the time of transition to End of Life Care

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AngCN-CCG-PS46

Referral Guidance for Cancer Psychological Support Services

Anglia Cancer Network

Obviously assessment is not confined to the above times and psychological support and assessment is also integral to specific Survivorship programmes and End of Life needs. Assessments should include identifying that the primary reason for distress or other psychological concerns are predominantly related to the cancer. Where primary reason(s) for psychological distress are related to other factors, then referrals should be made to mental health services or referred back to the patients GP. It also needs to be noted that referral can be made by any health and social care professionals involved in the care pathway of the patient if the need is identified.

3 REFERRAL CRITERIA 3.1 Issues that may give rise to referrals

Examples of the issues that might give rise to referral to level 3 or 4 are given below and need to be related to the impact that cancer is having on the patients ability to cope with every day living, treatment and existential issues. Some of the issues may be experienced as part of the adjustment process and may be contained by informal support. When the concerns or issues either seriously challenge coping mechanisms and /or give persistent distress for two weeks plus, then a referral is advised. .            

Coping with a sense that the future is uncertain Coping with how cancer affects relationships Managing the demands of home and family life while caring for oneself Uncomfortable feelings, e.g. depression, anxiety, anger Coping with disfigurement and disability Body image Coping with adjustment, change, loss Coping with pain, discomfort, fatigue and treatment side-effects Coping with how cancer affects sexual functioning and sexuality Coping with how cancer affects self-esteem and sense of self Suicidal ideation Organic brain syndromes

3.2 Situations inappropriate for referral

When the impact of cancer impacts on pre-existing mental health issues, and these mental health issues are the primary focus. In these circumstances involving and forming working partnerships with other mental health professionals is strongly advised in addition to discussing with the patients GP.

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AngCN-CCG-PS46

Referral Guidance for Cancer Psychological Support Services

Anglia Cancer Network

3.3 Family members

Unless there is a specific service related to Family Support, family members need to be referred back to their GP for particular psychological support. It is assumed that informal emotional and psychological support will be provided to the family as a whole by all members of staff who are involved in the patients’ pathway as a matter of course and in line with level one of the Four Level Model of Psychological Intervention.

4 THE REFERRAL PROCESS Before referring to level 3 or 4 it is important to establish that support cannot be provided by      

Clinical nurse specialist / key worker / AHP or ward/ outpatients team/staff Chaplaincy Complementary therapy team Pain management team Palliative care team Any other groups that are available, including those associated with Survivorship

In making a referral to Cancer Psychological Support services it is important that the health professional understands the role and remit of cancer psychology so that referrals can be made appropriately and in accordance with the NICE Guidelines. It is important that the patient agrees to being referred to a psychologist or counsellor. In addition to consent issues it is unlikely that the therapeutic process will be productive without the agreement, trust and co operation of the patient. However, there are occasions in which the refusal of a referral is a manifestation of adjustment and coping problems (e.g. extreme denial or avoidance) which warrant the referral in the first place. In that case it is recommended that the referring professional contacts the relevant psychologist/counsellor to explore possible options for assessment and intervention. The patient could be persuaded to meet with the psychologist/counsellor on a more informal basis. Alternatively the level 3 or 4 practitioner can advise on what action to take. In circumstances where there is a level three service only (i.e. no level 4) then referral to this level 3 service for assessment as to the level of intervention required is appropriate. If it is beyond the remit of the level 3 Counsellor or Junior Psychologist then referral to a generic Clinical Psychologist or Psychiatric Service needs to be discussed, preferably at MDT or directly with the services suggested. The GP needs to be involved in this process. In an emergency the generic emergency psychiatric liaison referral route should be used. This may vary from locality to locality and needs to be clearly identified on a local level. Page 5 of 11 Approved and Published: December 2011 \\195.104.155.28\data\Cancer Network\Cross Cutting Groups\Supportive & Palliative Care\psychology\Documents\Active\AngCN-CCG-PS46_v2 Referral Guidance for Psychological Support Services.doc

AngCN-CCG-PS46

Referral Guidance for Cancer Psychological Support Services

Anglia Cancer Network

In cases of suicide ideation a referral has to be made preferably in partnership with the GP and Consultant. This needs to be clearly documented. It should be made clear to patients where they will be seen e.g. at their hospital, hospice, or in the community and that the appointment could be up to 60 minutes long but the therapist will be led by the patient if they prefer a shorter meeting or if they are too frail to sustain a full session.

5 MAKING A REFERRAL 5.1 Who can make a referral?

Referrals can be made by any Health Care Professional involved in the patients care, but primarily this will be those working in the capacity of Key Worker or potential key worker e.g. Specialist Nurses and AHPs. 5.1.1

Non-NHS Referrals

If patients are referred via Support and Information Centres then governance issues need to be in line with that of the NHS Provider being referred to and the patient has to be a patient undergoing treatment or follow up reviews under a Consultant based within the Oncology Service. Recordable referral routes need to be evidenced. Joint working frameworks should be established to reflect the referral process and to allow for MDT working. This of course should not affect confidentiality as regards any disclosures made by the patient. 5.2 How to make a referral

Referrals must be made using referral forms designed at local level to suit local needs or by letter. Referrals should be documented and form part of the record keeping process in order to comply with governance. The appendix in section 9 lists the current network practitioners at levels 3 and 4, along with their contact details. They will advise on the format required for referrals to them. 5.3 When there is no level 3 or 4 member of the MDT

If there is no level 3 or 4 service available refer to the GP to make an assessment and to refer to Mental Health Services if appropriate.

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AngCN-CCG-PS46

Referral Guidance for Cancer Psychological Support Services

Anglia Cancer Network

6 ILLUSTRATION OF REFERRAL ROUTE Holistic Assessment

STEP 1   







Identify concerns Provide support Offer simple interventions if appropriate, as per level 2 training. Make any referrals for Support Groups/ Benefits Advice, Complementary Therapies etc Refer for psychosexual counselling if need identified Go to step 2 or 3 if necessary

STEP 2 





 

Refer to level 3 or 4 service as available and appropriate If not available refer back to GP or to mental health services Go to step 3 if necessary

STEP 3 Liaise with Psychiatric Services & GP Refer to Emergency Psychiatric Services

7 EXAMPLES OF CASES TO DEMONSTRATE RATIONALE FOR REFERRAL This is not the development of a single case over time, but an illustration of four separate hypothetical cases of increasing complexity. The same personal details and diagnosis have been used for easier comparison.

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Referral Guidance for Cancer Psychological Support Services

Anglia Cancer Network

Mrs Smith, 42, is married and the mother of two children (a boy,12 and a girl,15). She has been diagnosed with breast cancer which is being treated with a lumpectomy, chemotherapy and radiotherapy. Level 1 – All health and social care professionals Her prognosis is hopeful but still uncertain. She is approaching the end of her chemotherapy and has been off work for six months. She is fatigued, describes herself as a bit flat and listless. She finds herself thinking about her cancer a lot and feels unusually irritable with her husband and children. Assessment – informal - recognition of psychological needs. Intervention – Effective information giving, compassionate communication and general psychological and emotional support. Level 2 – Health and social care professionals with additional experience In addition to the above, Mrs Smith feels she often does not want to see people. She frequently expresses worry about the future and about bodily symptoms, which are aggravated by uncomfortable side-effects from chemotherapy and radiotherapy. There are times when she can enjoy herself but often she feels a bit anxious and low in mood. On the whole, however, she feels that she is coping. She is seen by her Specialist Nurse who has been trained to screen for psychological distress and provide some low key interventions. This assessment fits in with the key stage associated with treatment, but could have occurred anyway. Assessment - Screening of psychological distress, using the Holistic Assessment Model Intervention - Behavioural techniques such as problem solving, relaxing interventions e.g. breathing exercises. Level 3 – Trained and accredited professionals Mrs Smith has been feeling low for several months. She feels tired and achy, overwhelmed with household tasks and worries that she is not able to be a good mother and that she has become a burden on her family. She is convinced that the cancer will return. She feels that she has lost the person she used to be, feels disfigured and unattractive and that she is drifting apart from her husband. He appears unable to talk about her fears and has stopped touching her. She has begun dreading a return to work and has lost confidence; she had her first panic attack going out last week. Assessment- Evaluation of psychological distress and diagnosis of some psychopathology Referral to level 3 or 4 Page 8 of 11 Approved and Published: December 2011 \\195.104.155.28\data\Cancer Network\Cross Cutting Groups\Supportive & Palliative Care\psychology\Documents\Active\AngCN-CCG-PS46_v2 Referral Guidance for Psychological Support Services.doc

AngCN-CCG-PS46

Referral Guidance for Cancer Psychological Support Services

Anglia Cancer Network

Intervention- Counselling and specific psychological interventions such as anxiety management, CBT, delivered according to an explicit theoretical framework. Level 4 – Mental Health Specialists Mrs Smith feels hopeless and depressed and has thoughts of ‘just ending it all’. This frightens her as it reminds her of the nervous breakdown she had five years ago when her mother died of breast cancer. She is convinced that her daughter will ‘inherit’ breast cancer too and feels devastatingly guilty about this. Meanwhile biopsy showed tumour spread and eventually she had to have mastectomy; now she feels an ‘ugly freak’, and this evokes feelings about when she had anorexia nervosa as a teenager. Her husband is frustrated with her withdrawal and, feeling angry and helpless, has started spending a lot of time at the pub. His work is suffering and that increases her fears about finances. Their daughter seems more withdrawn and their son has been getting into trouble at school a lot. Assessment - Diagnosis of severe distress or psychopathology Referral to level 4 Clinical Psychology Intervention – Specialist psychological and psychiatric interventions

8 MONITORING THE EFFECTIVENESS OF THE GUIDANCE a) Process for Monitoring compliance and Effectiveness - Review of compliance as determined by audit. Any non compliance to be presented by PQ Manager to the AngCN Business Meeting on a quarterly basis – the minutes of this meeting are retained for a minimum of five years. b) Standards/Key Performance Indicators – This process forms part of a quality system working to, but not accredited to, International Standard BS EN ISO 9001:2008. The effectiveness of the process will be monitored in accordance with the methods given in the quality manual, AngCN-QM Equality and Diversity Statement This document complies with the Suffolk PCT Equality and Diversity statement – an EqIA assessment is available on request to Anglia Cancer Network PQ Manager, Gibson Centre, Exning Road, Newmarket, CB8 7JG. Disclaimer It is your responsibility to check against the electronic library that this printed out copy is the most recent issue of this document. Please notify any changes required to the Anglia Cancer Network Quality Manager Document management Document ratification and history Approved by: Annie Hallett, Network Lead for Psychological Services Date approved: December 2011 Date placed on electronic library: Review period: 2 years (or earlier in the light of new evidence) Authors: Psychological Services Steering Document Owner: Group Version number as approved and published: 2 Unique identifier no:

December 2011 Anglia Cancer Network ANGCN-CCG-PS46

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AngCN-CCG-PS46

Referral Guidance for Cancer Psychological Support Services

Anglia Cancer Network

9 APPENDIX – DIRECTORY OF PSYCHOLOGICAL SUPPORT Provider Peterborough: City Hospital . Thorpe Hall, Sue Ryder , Hospice

Name

Designation

Contact details

Level 4

01733 330060

Jane Pope Jane Pope

Cambridge: Addenbrookes

Nadine Hobro

Arthur Rank

Heather Styles

TYA Cancer Service

Jo Fretwell

Hinchingbrooke

N/a

Great Yarmouth & Waveny : James Paget Hospital NHS Trust

Nicky Downs

Level 4 Macmillan Evelyn Trust Consultant Clinical and Health Psychologist, Palliative Care

Level 3 Psychological Therapist

Level 3/4 Senior Counsellor (patients13-24 yrs from anywhere in East Anglia plus close family members)

Level 3 Counsellor

Palliative Care Service, Box 63, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 2QQ 01223 274 404 Nadine.hobro@addenbro okes.nhs.uk

01223 723118 [email protected] k

01223 349270 jo.fretwell@addenbrookes .nhs.uk

01493 452166

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AngCN-CCG-PS46

Referral Guidance for Cancer Psychological Support Services

Anglia Cancer Network

Kings Lynn: Queen Elizabeth Hospital NHS Trust

Alison Piper

Level 4 Clinical Psychologist (generic, but will see oncology patients)

01553 613663

Norwich & Norfolk University Hospitals NHS Trust

Mime Mathews (Breast Care only)

Level 4 Clinical Psychologist

Tel 01603 286732

Level 4 Family Systemic Therapist

Stephanie Barker Consultant Nurse Palliative Care Priscilla Bacon Centre for Specialist Palliative Care Services Norfolk Community Health & Care NHS Trust

Limited hours Pricilla bacon Lodge , Norwich

Stephanie Barker

(t) 01603 723802 (f) 01603 661444 [email protected] hs.uk West Suffolk Hospital NHS Trust

Sandy Doyland

Level 3 Sandy Doyland MBACP (Accredited), UKRCP Psychotherapist / Counselor BA (Hons), Diploma Clinical Supervision

Mobile: 07545 950666

St Nicholas Hospice

David Rushton

Level 4 Counselling & Psychotherapy

01284 766133

Catherine Proot

Ipswich Hospital NHS Trust

Sue Hambleton

Level 3 Counsellor

01473 704903

St Elizabeth Hospice Ipswich

Family Support/ Counselling

Level 3

01473 727776

Bedford Hospital NHS Trust

N/A

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