Ensu

rin

g B

ette

r Tr

eatm

ent

Quality in Nursing

Excellence in Cancer Care: The Contribution of the ClinicalNurse Specialist

National Cancer Action TeamPart of the National Cancer Programme

22

Contents

Foreword 3

The role of the Clinical Nurse Specialist in cancer care 4

The cost of managing cancer 5

Reducing the financial burden of cancer – the potential of the CNS 6

CNSs: leading quality and productivity in cancer care 6

Experience from the front line – CNSs transforming cancer care 7

Case Studies 8

Delivering the future for cancer patients 11

Matching workforce planning to patient need 11

Issues for Employers and Managers to consider 12

Further sources of information 13

Acknowledgments 13

References 14

Endorsements 15

Key contributions that CNSs make to cancer care 5

33

Together we share an ambition to achievethe best cancer outcomes for patients in theUK, recognising that, at a time of tightenedbudgets, it is critical that NHS resources aredeployed to best effect. Now more thanever, clinical nurse specialists (CNSs) have avital role to play in delivering high qualityand compassionate care, including carecloser to home, and supporting a drive forefficiency that improves health outcomesand maximises resources.

Cancer CNSs have played an important rolein the successful implementation ofinitiatives to improve NHS cancer services.Despite an increasing incidence of thedisease and an ageing population, deathrates from many cancers are dropping,survival rates are improving and manypatients’ experiences of care have beenenhanced. CNSs are at the front line ofcancer care; they are the main point ofcontact for patients and as a result help toshape services for each patient according toneed and patient choice, which contributesto wider cancer priorities. For example,CNSs play an important role in enablingcare to be delivered closer to home and inimproving patients’ and their families’ability to self-manage symptoms and side-effects of treatment.

CNSs contribute to increasing the quality ofcare provided by the NHS; indeed, in theface of rising patient expectations, morepatients report being treated with dignityand respect and having trust andconfidence in their care team. Increasingly,they have an ongoing role in supportingcancer survivors as well as cancer patients.Overall it is estimated that there are now 2million people living with cancer and this isset to rise to 4 million by 2030.1

For people affected by cancer, the effectivemanagement of their care pathway is

essential to maintainquality of life. Peoplewhose care isunplanned and un-coordinated are morelikely to be high usersof health and socialcare services,including emergency

care. CNSs work closely with patients andwith their clinical colleagues to adapt topatients’ emerging needs thus reducing theneed for unplanned care.

This short guide is designed to supportclinical teams, commissioners, employersand managers to understand and evaluatethe contribution of CNSs in cancer as theyplan their local workforce and serviceimprovement strategies. With examplesdrawn from front-line services across arange of cancers, this guide sets out howeffective CNS deployment drives innovation,reduces inefficiency and improves thequality of cancer care across the UK.

We still have further to go if we are toimprove outcomes for all cancers, with theaim of bringing us in line with the best inEurope. Ensuring provision of CNSs wherethey are needed, coupled with effective useof their skills and expertise will enable us tomove faster towards this goal.

Professor Sir Mike RichardsNational Cancer Director

Ciarán Devane Chief ExecutiveMacmillan Cancer Support

Dame Christine Beasley DBEChief Nursing Officer (England)Department of Health

Foreword

24

The roles undertaken by Clinical NurseSpecialists (CNSs) are many and varied;however, there are core clinical practicefunctions and a level of practice that couldbe reasonably expected of all CNSs in cancercare.

CNSs in cancer care can be described asregistered nurses, who have graduate levelnursing preparation and who would usuallybe expected to be prepared at Master’slevel. They are clinical experts in evidence-based nursing practice within a specialtyarea. The specialty may be focused on apopulation (e.g. young people), type ofcare (e.g. palliative care), type of problem(e.g. lymphoedema), type of treatment (e.g.chemotherapy) or tumour type (e.g. lungcancer).

CNSs treat and manage the health concernsof patients and work to promote healthand wellbeing in the patients they care for.CNSs in cancer care practice autonomouslyand integrate knowledge of cancer andmedical treatments into assessment,diagnosis, and treatment of patients'problems and concerns.2 Whilst manyspecialist nurses may function at anadvanced level, this level of practice is notcommon to all, thus the title Clinical NurseSpecialist does not in itself indicate that thenurse is an ‘advanced practitioner’.

The high-level activities of CNSs can beseparated into four main functions.3 In thecontext of cancer care these consist of:

1 Using and applying technical knowledgeof cancer and treatment to oversee andcoordinate services, personalise ‘thecancer pathway’ for individual patients

and to meet the complex informationand support needs of patients and theirfamilies

2 Acting as the key accessible professionalfor the multidisciplinary team,undertaking proactive case managementand using clinical acumen to reduce therisk to patients from disease ortreatments

3 Using empathy, knowledge andexperience to assess and alleviate thepsychosocial suffering of cancer includingreferring to other agencies or disciplinesas appropriate

4 Using technical knowledge and insightfrom patient experience to lead serviceredesign in order to implementimprovements and make servicesresponsive to patient need

Furthermore, some cancer CNSs havedeveloped their roles to include technicalelements, for example: physicalexaminations and diagnostic tests; andinsertion of central venous lines for thedelivery of chemotherapy or for nutritionalpurposes.

Many cancer CNSs work as part of a tumourspecific team, whereas others may workacross more than one service or setting.Although many are based within acutetrusts, post-holders are also located inprimary care and community settings orprivate and voluntary sector organisations.They may be responsible for whole clientgroups, or for episodes of care and nursingservices more widely. They are also typicallycore members of a multidisciplinary team.4

The role of the Clinical NurseSpecialist in cancer care

35

Acting as akey workeracross the whole carepathway Advanced

clinical /diagnostic

skills

Innovation,project

managementand change

management

In-depthknowledgeof a tumour

areaClinical NurseSpecialist

Leadershipwithin

the MDT andwider cancer

team

Excellentdecision-makingabilities

Ability toassess

patients’holistic needs

Advancedcommunicationand advocacy

skills

Empathyfor patients

and theirfamilies

Key contributions that CNSs make to cancer care

The cost to the NHS in England of patientcare for cancer in 2007/8 was £5 billion.5

Department of Health figures for 2007-08showed that:

• Over half (i.e. over £2 billion) of the totalexpenditure on cancer in England wenton inpatient care6

• Inpatient care for cancer patientsaccounted for 12% of all inpatient bedsin England6

• The number of emergency admissions forcancer increased by 47% in the past 8years6

• 4.7 million bed days were cancer related6

Statistics from 2006-07 for England show:

• 417,646 emergency inpatient admissionsfor cancer representing 2,963,987 beddays6

• 339,038 elective inpatient admissions forcancer representing 1,750,223 bed days6

The cost of managing cancer

26

The specialist nature of the cancer CNS andtheir role as key worker to individualpatients means that they can quicklyidentify emerging issues that might requiremedical attention, enabling care to beplanned and emergency admissions averted.CNSs also support enhanced recovery aftersurgery – equipping patients to managetheir recovery at home and reducing theneed for lengthy hospital stays. These twoimportant contributions help the NHS toimprove patient experience and safety.

There are also sound economic argumentsfor supporting patients to manage theircare at home and helping them through thecomplex systems of health care provision.

The National Audit Office’s End of Life Carereport estimated £104m savings by reducingemergency admissions by 10 per cent, andreducing the length of stay by 3 days.7

An economic modelling analysis byMacmillan Cancer Support in 20098,focusing on the role of the CNS, suggestedthat service improvements along the cancerpathway could release about 10% of cancerexpenditure in the Manchester area. Thisrelated only to breast and lung patientsadmitted through the two week waitsystem in one health economy. Ifextrapolated to a national level then theeconomic benefits could be significant.

Reducing the financial burden of cancer– the potential of the CNS

Patients rightly expect high quality,effective healthcare and CNSs have animportant role to play in meeting theirneeds and expectations.

The proposed NHS Outcomes Framework9 isstructured around five high level outcomedomains. These are intended to covereverything the NHS is there to do. Thesefive outcome domains are:

• Preventing people from dyingprematurely

• Enhancing the quality of life for peoplewith long-term conditions

• Helping people to recover from episodesof ill health or following injury

• Ensuring people have a positiveexperience of care

• Treating and caring for people in a safeenvironment and protecting them fromavoidable harm

As practitioners and partners at the heart ofmultidisciplinary teams, CNSs have influenceand credibility across the care pathway.They are increasingly taking a leadershiprole in refining systems and smoothing carepathways, making a demonstrablecontribution to effectiveness, patientexperience and safety.

CNSs: leading quality and productivity in cancer care

37

Improving quality andexperience of care• Managing complex, individual and

changing information and supportneeds of patients and carers

• Supporting patients in choicesaround treatment and care

• Enhancing recovery and deliveringcare flexibly and closer to home

• Facilitating set up of support groups

Increasing productivity and efficiency• Intervening to manage treatment

side effects and/or symptom control,preventing unplanned admissions

• Providing nurse-led services thatfree up consultant resource

• Empowering patients to self-manage their condition

Reinforcing safety• Delivering safe, nurse-led services

• Using vigilance of symptoms anddrug toxicity to trigger rescue work

• Identifying and taking action toreduce risks

• Facilitating rapid re-entry into acuteservices, if appropriate

Demonstrating leadership• Educating the wider healthcare

team and acting as a mentor

• Identifying and implementingservice improvement andefficiencies

• Determining measurable outcomes,auditing practice, and sharing goodpractice and innovation

CNSs across the country are alreadytransforming patients’ experiences ofcancer care. The following case studiesprovide a flavour of the kinds of initiatives

that CNSs are leading – highlighting theirpivotal role in maximising resource andbenefitting patients.

Experience from the front line –CNSs transforming cancer care

Impact of keyCNS-led activites

28

CNSs in Doncaster and Lincolnshirehave implemented rapid alertsystems to ensure that they areimmediately informed when one oftheir patients enters hospital withan unplanned admission. Usingmobile technology and integratedIT systems, a text message andemail is sent to the CNS who canimmediately attend the patient ordiscuss the case with the treatingclinicians.

Using their specialist knowledge inlung cancer, and theirunderstanding of individualpatients’ needs, CNSs inLincolnshire use this as anopportunity to re-assess thepatient’s cancer pathway outside ofscheduled patient planning, oridentify where a quick specialistintervention can turn around aninappropriate admission. Thenurses in Doncaster have identified

length-of-stay reductions of one totwo days per patient, they work toensure that the patient is admittedto the correct ward and in somecases prevent admission altogether.Added to these productivitybenefits is the increased quality ofcare experienced by patients whoreport feeling completelysupported, knowing that they arereceiving coordinated care.

Case Studies

Frances, and her colleaguesCaroline Williams and PatCameron, run the only lung cancerand mesothelioma support groupin their Cancer Network. Up to 28people each month attend thegroup.

The CNSs work in collaborationwith a local hospice to facilitate the

monthly group meetings with ahospice volunteer managing themeeting practicalities. A successfulbuddy system has been establishedfor patients and carers who facethe challenging and complex issuesof a terminal disease.

The group also enables the CNSs toidentify emerging health issues,

including helping patients to self-manage symptoms such asshortness of breath, reducinganxiety and maintaining quality oflife. Importantly, the CNSs are ableto mediate between patients andhospital services and quicklyaddress any issues of concern raisedby patients and their families.

Nurses fromthe children’s

oncologyoutreach service in Newcastle workwith children and young peoplethroughout their cancer journeys.Using specialist knowledge ofsymptom management, palliativeand complex care, the nurses worka 24/7 on-call system, allowing fortimely, effective interventionswhich maximise care delivery. Thenurse team are trained as non-medical prescribers, and more thanhalf are practising prescribers.

Working in a large geographicalregion, the nurses have developedeffective collaborative workingpractices with local primary careservice providers. This is particularlyimportant in enabling children andyoung people with progressivedisease to be cared for, and die, intheir preferred place of choice,often their home.

The nurses are leading the way inthe implementation of newtechnologies in their hospital trust.“Smart Pump” technology,

considered to be the nextgeneration of ambulatory infusiondevices, allows the release ofmedication over seven days -maximising symptom managementand minimising hospitalattendance. Corresponding druglibraries, managed by the nurses,help to improve safety by reducingdrug errors, improving workflowand providing a new source of datafor continuous qualityimprovement.

Innovation, project management, changemanagement

Lesley Barnett, Macmillan Lead Cancer Nurse, DoncasterGina Wibberley, Macmillan Lung CNS, Lincoln

Empathy for patients and their families

Frances McKay, Macmillan Mesothelioma and Lung CNS, Medway

Advanced clinical and diagnostic skills

Sharon McGeary and Amanda Gerrard, Paediatric Oncology OutreachNetwork CNSs, Newcastle Upon Tyne

39

Tina and thecolorectal

specialist nurses provide qualityservices to enhance recovery forpatients with colorectal cancer atthe Countess of Chester Hospital.Through a pre-operativecounselling initiative, patients andcarers have an increasedunderstanding of recovery anddischarge expectations, helping

them to make plans for managingcare at home. In addition, patientswho are expected to have a stomaare visited at home by the stomanurse for a ‘dummy’ teachingsession, reducing the time it takesto become self-sufficient in stomamanagement.

Patients on the enhanced recoveryprogramme are discharged as earlyas two days after surgery, and

there is evidence that this issignificantly reducing care costs.The colorectal specialist nursescontact the patient daily afterdischarge for up to 10 days toassess their progress. This vigilanceensures that complications arepicked up early enabling timelyintervention, and patients reportfeeling supported through theirrecovery.

Debbie hasdeveloped aninnovativeearly-alert

service for women with ovariancancer who suffer from a painfuland distressing build up of fluid inthe abdominal area.

Patients are alerted to thepossibility of fluid build-up, andencouraged to phone her if theybegin to experience symptoms.When contacted, Debbie makes aclinical assessment, organising anabdominal scan if required andbooking blood tests pre-admission.The drainage can then be done as aday patient, preventing emergency

admission to A&E and lengthyinpatient stays as well as improvingpatients’ quality of life.

The CNS’s coordinating role ensuresthat phlebotomists, radiographers,and the medical team are allavailable at the right time. Debbiehas developed this into a protocol -now widely used.

Judith has developed an innovativesystem to monitor and bestmanage anxiety among patientsrecalled to the breast screeningclinic for further assessmentfollowing attendance to the NHSbreast screeningprogramme. Judith devised asimple tool that encouragespatients to reflect on their anxietyand prompt them to seek

additional support from the breastcare nurse (BCN). It also promotesgreater collaboration withradiographers and a morecoordinated patient-centredexperience.

Designed to look like athermometer, the assessment toolasks women to score themselvesfrom 0-10 (low to high anxiety)enabling BCNs to triage the more

vulnerable women (scoring 5 andabove) and ensure they are offereda BCN consultation before beingre-screened. Radiographers also usethe self-assessment to ensure morepatient-focused care, taking intoaccount women’s concerns.Feedback from patients shows thatwomen find this activity useful andmany have commented on how ithelped to reduce their anxiety.

Acting as key worker across the whole care pathway

Tina Lightfoot, Lead Specialist Nurse for GI services (surgery), Chester

Excellent decision making abilities

Debbie Fitzgerald, Gynaecology CNS, Torbay

Advanced communication and advocacy skills

Judith Clarke, Surgical Breast Care CNS, Coventry

210

Case Studies (continued)

Catherine and the team ofchemotherapy nurse specialists atGuy’s and St Thomas’ Hospital havebeen working together to redesignthe way chemotherapy is delivered.Nurses in the chemotherapy unitnow work in four specialised teamsaccording to tumour types toimprove consistency for patientsand maximise the nurses’ clinicalexpertise.

Catherine piloted an interventionin urology in which a specialistnurse and pharmacist delivered animproved pre-treatmentconsultation. The key to its successis structuring the consultation toensure that patients’ educationaland supportive care needs are metto optimise safety and empowerpatients to actively participate intheir treatment plan. Additionally,

CNSs proactively call patients tomonitor their progress during thecourse of their treatment. Closelymonitoring patients in this wayensures that any side-effects can bequickly managed and that patientsare supported through thissometimes difficult part of theircancer journey.

Analysis of patient experience atUniversity Hospital of North Teessuggests that lung cancer patientsand carers can encounter problemsfollowing admission to theEmergency Assessment Unit (EAU).These include unnecessaryinvestigations, poor symptommanagement, lack of recognitionof end of life, delays in dischargeand inadequate communication.

This has a negative impact onpatients’ confidence in the serviceand also on the length of staywhich has a cost implication.

The CNSs at North Tees use theirspecialist knowledge of lung cancerto support patients who areadmitted as emergency cases,reducing inpatient stays andhelping patients and carers to

understand and manage symptoms.University Hospital of North Teesexamined a total of 94 inpatientepisodes resulting in 964 bed days.The average length of stay forthose patients not referred to thelung CNS was 10.8 days howeverthere was a reduction in length ofstay to 9.7 days for those patientswho had lung CNS input duringtheir admission.

Anita workswith patientsthroughout

their cancerjourney but has particularlyfocussed on supportingsurvivorship and smoothing thetransition from secondary toprimary care.

Six to eight weeks post-treatment,she provides patients with detailed

and individual ‘end of treatment’summaries within the context of aholistic consultation. This capturestheir initial diagnosis andtreatment history, medication andfollow-up schedule - incorporatingthe wider services they haveaccessed, such as limb-fitting andsupport groups. The summary alsoacts as an importantcommunication tool for their GP,

enabling greater integrationbetween different parts of thepatient pathway.

The summary and assessment hasproved valuable to patients -increasing their confidence andability to self-manage - as well asto primary care - improvingappropriate referral if and whenneeded.

Demonstrating Leadership

Catherine Oakley, Nurse Consultant, London

In-depth knowledge of tumour area

Tessa Fitzpatrick, Macmillan Lung CNS, North Tees

Ability to assess patients' holistic needs

Anita Pabla, Sarcoma CNS, Leicester

311

Delivering the future for cancer patients

The NHS White Paper, Equity andExcellence: Liberating the NHS, putspatients and clinicians at the heart ofdecision-making in the NHS. The phrase “nodecision about me without me” is used inthe White Paper to emphasise patients’involvement in their own care.10 CNSs areoften the main point of contact for cancerpatients and their families, and work closelywith colleagues throughout the patient’scancer journey. As a result, they are wellplaced to support patients at each stageand to promote integration within careteams.

Equity and Excellence proposes a shift awayfrom measuring clinical inputs andprocesses in favour of achieving improvedclinical outcomes and higher quality patientexperience. Here too, CNSs alreadydemonstrate their skills in assessing andputting in place interventions to achievethese.

The Cancer Reform Strategy (2007) statedthat: “Commissioners and providers shouldensure that the critical roles of clinical nursespecialists in information delivery,communication and coordination of care

are supported”.11 This remains essential toachieving safe and high quality cancer careand we expect to see this reflected in therefreshed Cancer Reform Strategy.

Nursing is changing, reflecting andrewarding the skills and expertise of itsworkforce. Career pathways have beenupdated and transferable skills identified toenable nurses to shape their careers withinand across different care pathways.12

Embracing new models of care, the CNS roleextends beyond the hospital setting intolocal community and specialist settings andincreasingly includes informed individualcare planning that enables patients to self-manage their condition where possible.

There is wide variation in the types of tasksthat CNSs are carrying out. While some ofthese make good use of their skills, there isevidence that CNSs are also being divertedinto general ward duties and tied up inadministrative tasks. This does not representgood value to the NHS. Commissioners,employers and managers therefore need toconsider whether CNSs are being deployedto best effect.

Clinical teams will be considering whetherprovision of CNSs in their local area issufficient to meet need. Understanding thepatterns of access is fundamental to beingable to match the CNS workforce topatients’ needs. Despite the expansion inoverall CNS numbers since the 1980s,workforce shortages are still an issue.13

The best available data indicates that notevery cancer patient has access to a CNS,despite the recommendations made in theImproving Outcomes Guidance. TheNational Cancer Action Team’s WorkforceReview Team 2010 census demonstratessignificant variation in provision of cancer

CNSs in England, which cannot beaccounted for by geographical differencesin cancer incidence or in patient flows.14

Since the last census in 2008,15 thereappears to have been an increase in CNSposts in rarer cancers, but the 2010 censusrevealed no significant growth in othertumour groups despite increasing cancerprevalence. Inequities remain acrossEngland and also between different tumourtypes. Patient advocacy groups have arguedthat in some cancers - notably lung andurological cancers - CNS provision fallssignificantly short of patient need and thatCNSs face variable case-loads.

Matching workforce planning to patient need

212

CNSs provide quality care and contribute toimproved outcomes for cancer patients.They lead innovation, and can driveefficiency in their teams. They alsocontribute to the delivery of healthstrategies and policy guidance including:

• Cancer Reform Strategy

• Improving Outcomes

• Quality, Innovation, Productivity andPrevention Challenge

• High Impact Actions for nursing andmidwifery

• Equity and Excellence: Liberating the NHS

• Chemotherapy Services in England

• Vital Signs

• End of Life Care Strategy

Employers and managers may wish to askthe following questions when consideringtheir cancer services and assessing their CNSprovision, to identify to what extent cancerservices are configured to maximise thesafety, quality and productivity of care:

Your community

• What is the all-age, all-cause cancerincidence rate in your PCT?

• What are the demographics of your PCTin terms of: age; socioeconomic anddeprivation factors; prevalence of riskfactors; ethnicity?

• Are there communities with particularunmet needs?

• What priority issues for cancer have beenidentified through the Joint StrategicNeeds Assessment?

• How have you reflected these in theselection of local priorities and incentivesfor health care providers e.g CQUINs?QOF?

• How do you plan to measure andimprove outcomes in these areas?

Provision and capacity

• How many whole-time equivalent CNSsposts are there in your PCT?

• What is the distribution of these acrossdifferent cancers?

• How does this compare to patterns inneighbouring areas and to the nationalpicture?

• Does each specialist team dealing with aparticular cancer type have at least oneCNS member?

• How good is CNS attendance at MDTmeetings for each team?

• How many new patients does each CNSsee each year?

• Have you considered using the expertiseof the Macmillan Cancer Support ServiceDevelopment Team to redesign CNS rolesand services should you have concernsthat CNSs may not be working to the bestpotential of their roles?

Where can CNSs make most impact?

• How many unplanned admissions arethere for cancer each year in your PCT?And how does this vary by cancer type?

• Do audited records demonstrate that atleast 80% of patients receive informationabout their diagnosis, treatment and careplan?

• Can it be demonstrated that care iseffectively coordinated acrossboundaries?

• Are CNSs working in roles that reflectand demand their knowledge and skillsor are they undertaking general wardduties?

Issues for Employers and Managers to consider

313

• Cancer Commissioning Guidancehttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_110115

• Cancer Commissioning Toolkithttps://www.cancertoolkit.co.uk

• Cancer Reform Strategy and AnnualReportshttp://www.dh.gov.uk/en/Healthcare/Cancer/ReformStrategy

• National Cancer Intelligence Networkhttp://www.ncin.org.uk

• Association of Public HealthObservatorieshttp://www.apho.org.uk/

• Public Health Observatory Handbook ofHealth Inequalities Measurementhttp://www.sepho.org.uk/viewResource.aspx?id=9707

• Guidance on Joint Strategic NeedsAssessmenthttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081097

• The Operating Framework for the NHS inEngland, 2010/11 (December 2009)http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_110107

• Specialist nurses. Changing lives, savingmoney. Royal College of Nursing, London.2010http://www.rcn.org.uk/__data/assets/pdf_file/0008/302489/003581.pdf

• Programme Budgeting data for 2007-08http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/Programmebudgeting/DH_075743

• National Audit Office, End of Life Care,November 2008 available here:http://www.nao.org.uk/publications/0708/end_of_life_care.aspx

• Department of Health, Equity andexcellence: Liberating the NHS, July 2010http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf

• To download this publication go to:http://ncat.nhs.uk/our-work/ensuring-better-treatment/quality-in-nursing

Further sources of information

The Department of Health, National CancerAction Team and Macmillan Cancer Supportwould like to thank all those who havecontributed to the development of thispublication, in particular the Clinical Nurse

Specialists who provided examples of goodpractice, and the members of the NationalQuality in Cancer Nursing Steering Groupfor their advice and guidance.

Acknowledgments

2

1 Maddams J, Moller H and Devane C.,Cancer prevalence in the UK, 2008,Thames Cancer Registry and MacmillanCancer Support, July 2008

2 American Nurses Association. Nursing:Scope & standards of practice, 2004

3 Leary A (2011) in Leary A (Ed) Lungcancer a multidisciplinary approach,Wiley-Blackwell Oxford In press

4 National Cancer Peer ReviewProgramme Manual for Cancer Services2008: Breast Measures

5 Department of Health, ProgrammeBudgeting data for 2007-08

6 NHS Improvement Transforming Carefor Cancer Inpatients - Spreading theWinning Principles and Good Practice:July 2009

7 National Audit Office, End of Life Care,November 2008

8 Macmillan Cancer Support,Demonstrating the economic value ofco-ordinated cancer services. Anexamination of resource utilisation inManchester , March 2010

9 Department of Health , Transparency inoutcomes a framework for the NHS, July2010

10 Department of Health, Equity andexcellence: Liberating the NHS, July2010

11 Department of Health, Cancer ReformStrategy, December 2007

12 Department of Health, Towards aframework for post-registration nursingcareers - consultation response report,July 2008

13 National Cancer Action Team, NationalCancer Peer Review Programme 2004 –2007. An overview of the findings fromthe second national round of peerreviews of cancer services in England,June 2008

14 National Cancer Action Team WorkforceReview Team, Census of CancerSpecialist Nurses in English CancerNetworks, 2010

15 Trevatt, P., Leary, A., A Census of theadvanced and specialist cancer nursingworkforce in England, Northern Irelandand Wales, European Journal ofOncology Nursing (2009) 14:1 (68-73)

References

14

315

The content of this publication is endorsedby the following organisations:

Endorsements

Gateway Number: 14851

NCAT

Diagnosing Cancer Earlier

Prevention

Living

with

and

Beyond Cancer

Ensu

ring

Bet

ter

Trea

tmen

t

Impr

ovem

ent

In

telli

gen

ce

All rights reserved © Crown Copyright 2010