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Radiography 18 (2012) 34e37

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Radiography

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The Service Pledge for Breast Cancer e Improving services through patientinvolvement

Shauna Freeman, Ross Kester, Sally Greenbrook, Ruairi O’Connor, Sarah Rawlings*

Breakthrough Breast Cancer, Weston House, 246 High Holborn, London WC1V 7EX, United Kingdom

a r t i c l e i n f o

Article history:Accepted 17 November 2011Available online 7 December 2011

Keywords:Patient engagementImprovement goalsService improvementPatient surveyBreast radiotherapy

* Corresponding author. Tel.: þ44 2070252439.E-mail address: Sarahr@breakthrough.org.uk (S. R

1078-8174/$ e see front matter � 2011 The College odoi:10.1016/j.radi.2011.11.007

a b s t r a c t

A guiding principle for today’s National Health Service is for services to reflect the needs and choices ofpatients and carers. There is evidence that meaningful patient involvement and engagement of people intheir own care supports relationships with NHS professionals, and improves the quality and experienceof healthcare. This paper reviews the Service Pledge for Breast Cancer, developed by the charityBreakthrough Breast Cancer as a tried and tested route to delivering effective patient involvement andexamines some implications for radiotherapy services.

The Service Pledge, which has benefitted an estimated 19,000 patients across the UK, is a tool thatenables healthcare professionals and patients to work in partnership to improve local breast cancerservices. Based on the results of a patient survey and in depth interviews to determine to what extentstandards of care are being met at each participating hospital, improvement goals are identified helpingturn the patient voice into constructive action. Improvement goals resulting from the Service Pledgerange from small changes that make a real difference to patients, through to much larger changes to localbreast services.

To date, there has been limited involvement of radiotherapy staff in the Service Pledge, yet radiog-raphers play an important role in the treatment of breast cancer as most patients will be offeredradiotherapy. However, radiotherapy services have been criticised for not being patient -centred and fornot providing enough information, psychological and emotional support before, during and aftertreatment. It is contended that radiographers are ideally placed to address many of these concerns andengage further with patients through projects such as the Service Pledge, empowering their patients tovoice what is most important to them and driving the quality improvements that emerge.

� 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Introduction

In 2009, the Government published the National Health Service(NHS) Constitution; the first time in the history of the NHSa statement of what staff, patients and the public can expect from itwas bought together in one place. The Constitution sets out indi-vidual patient rights and key guiding principles; including that NHSservices ‘must reflect the needs and preferences of patients andtheir carers’. The Constitution also pledges that patients and thepublic will be provided with the information needed to influenceand scrutinise the delivery of services.1

The NHS Constitution reiterates section 242 of The NationalHealth Service Act,which saw theGovernment place a dutyon thoseworking in the NHS to involve patients in developing services.2 Thisduty of involvement is reflected in review mechanisms for NHS

awlings).

f Radiographers. Published by Else

services. For example, the Manual for Cancer Services, used for peerreview, states that breast multidisciplinary teams must surveypatients and implement at least one point as a result.3

Research by the Picker Institute has shown many patients wantto play an active role in their healthcare, ‘they want to know how toprotect and improve their health when they are well; when theyare ill they want information about treatment options and likelyoutcomes; and, in addition to seeking fast and effective healthadvice when they need it, most people also want to know whatthey can do to help themselves’.4 This suggests that deliveringgenuine patient involvement and engaging people in their owncare not only holds the key to more rewarding interactions for bothpatients and healthcare professionals, but can also improvehealthcare quality and experiences.5 In addition, engaging patientsin their healthcare and encouraging them to take responsibility forprotecting their health are seen as important for the long-termsustainability of publicly funded health systems.6

Involving patients in the design and delivery of services isparticularly important for radiotherapy, which over the years has

vier Ltd. All rights reserved.

S. Freeman et al. / Radiography 18 (2012) 34e37 35

come under intense scrutiny and criticism following the publica-tion of reports such as ‘What breast cancer patients want froma world class radiotherapy service’ in 2005,7 and the report of theNational Radiotherapy Advisory Group in 2007.8 These reports notonly highlighted the need for improvements in service delivery, butalso in communication, information provision, and psychologicaland emotional support before, during and after radiotherapytreatment.

Delivering effective patient involvement means taking accountof, and tailoring services to, the needs of different conditions as wellas individual patients. There are challenges in designing anddelivering such services, but examples of effective methods thathave facilitated the successful involvement of patients in their careand treatment exist. One such method is the Service Pledge forBreast Cancer, developed by Breakthrough Breast Cancer. With 26breast units up and down the UK having already taken part in theproject and a further 25 hospitals involved in 2011, the ServicePledge is a tried and tested route to delivering meaningful patientinvolvement.9 Of those hospitals that have so far taken part in theService Pledge 30% have on-site radiotherapy facilities and, whilstthe Service Pledge has not focused solely on this, patient feedbackhas included comments relating to the delivery of radiotherapyservices (both on-site and off-site). This indicates that there is muchthat radiotherapy services can learn, and radiographers can apply,to support and deliver continued improvements in this part of thecare pathway.

The Service Pledge for Breast Cancer

The Service Pledge for Breast Cancer was launched in 2002following a public consultation to promote dialogue and debateabout how to empower patients and to develop a consensus aboutthe standard of services offered to breast cancer patients. Over 700service users, healthcare professionals and policy makers, amongstothers, were involved in its development. The overwhelmingconsensus of those involved was whilst there had been manypositive changes to breast services, partly as a result of a renewedfocus on tackling cancer following the publication of the NHSCancer Plan,10 there was room for improvement.

The Service Pledge is a tool that aims to enable healthcareprofessionals and patients to work in partnership to improve localbreast services. Breakthrough Breast Cancer works closely withhospitals to develop their own ‘Service Pledge’ by carrying out an indepth patient experience survey and face-to-face interviews e

a patient audit e to determine to what extent standards of care arebeing met. A detailed multiple choice patient experience survey isposted to all patients treated within a 6 month period, following thepatient journey from referral through to follow up, and asks patientsto describe their care. Anonymous patient interviews allow fora much more detailed understanding of patients’ experiences. Inorder for patients to be fully open about their experiences of care, theinterviewers have themselves had a personal experience of breastcancer but have not been treated at the specific hospital taking part.All patient interviewers are trained by Breakthrough Breast Cancer tofulfil this role using a semi-structured interview technique, allowingpatients to talk about what matters most to them.

At each hospital taking part in the project, a member of thebreast care team, usually a breast care nurse takes on the lead rolein the project as the ‘Pledge Lead’. Up to two patient representativesare also identified to work closely with the Pledge Lead to under-stand and evaluate patients’ experiences of care. The Pledge Leadand patient representatives, working with the wider multidisci-plinary team, identify at least three realistic improvement goalsthat are likely to benefit a significant number of patients, balancing

the patient audit results with budgetary and clinical constraints.The aim is to turn the patient voice into constructive action.

Local Service Pledge booklets developed by individual hospitalsand based on the results of the patient audit are given to all patientsdiagnosed with breast cancer and set out the standards of care theycan expect to receive as well as the goals the hospital has set forimproving their service. The standards of care are based ona template developed in consultationwith healthcare professionals,patients and policy experts.11 The template draws together thelatest guidance from the Department of Health, National Institutefor Health and Clinical Excellence and professional bodies such asthe Association of Breast Surgery, and sets out the gold standard ofpatient care that every hospital should be striving to achieve.

Delivering effective service improvement

The Service Pledge project has been running for over 9 years andit is estimated that over 19,000 patients have benefitted across theUK. Improvement goals resulting from the Service Pledge rangefrom small changes that can make a real difference to patients,through to much larger changes to local breast services. Twoexamples of improvements that have been implemented as a resultof the Service Pledge are; introducing a photographic guide tobreast surgery and reconstruction that allows patients to betterunderstand the cosmetic results of surgery and assists with helpingthem make an informed choice, and establishing a formal buddysystem for patients with someone else who has undergone similartreatment before and after surgery. Larger improvements imple-mented include the establishment of a rural drop-in clinic in NorthYorkshire following feedback that women in this rural area expe-rienced poor public transport links. The new drop-in clinic allowspatients in the community to more easily contact their breast carenurses for information and support. In total, 60% of MDT memberswho responded to a staff evaluation survey about the ServicePledge in 201012 indicated they felt the improvement goals havebeen very important to the breast unit with none indicating thegoals had not been important.

The Service Pledge project was independently evaluated in2004, 2008 and 2010 to assess its methodology and impact.12

Whilst the Service Pledge for Breast Cancer has primarily focusedon working with individual breast units with breast care nursesacting as Pledge Leads, the evaluation of the project has shown thismodel of patient involvement and service improvement is flexibleenough to be adapted and applied to a wide range of long-termconditions and treatment settings across and beyond cancerservices. Healthcare professionals involved have been positiveabout the approach and in particular the tailored and exploratorynature, which seemed to distinguish it from other ventures e

“.what hasmade a difference is that it was very specific. It allowedus to move away from the generic questionnaires which tend to beused in the NHS towards a more tailored one, which actually looksat patient outcomes and experience as opposed to what we thinkwe would like to know”.

The evaluation findings of the Service Pledge project have alsoprovided a useful insight into the significant benefits that patientinvolvement can bring to both patients and staff. Patient involve-ment, if meaningful, is often in itself positive. Evidence suggeststhat user involvement can have a number of beneficial outcomesfor those involved: increased social contact, enhanced knowledgeand skills, expanded opportunities for learning and self-esteem,and an increase in confidence.13 By involving patients anddemonstrating commitment to working together in an open andtransparent way, healthcare professionals can help patients feelmore confident about the importance ascribed to their experiences,and therefore their care. The Service Pledge model builds on this by

S. Freeman et al. / Radiography 18 (2012) 34e3736

introducing improvements to the patient journey that in manycases might seem minor but make a big difference to individualpatient experience. For example, one particularly positivelyreceived improvement goal involved making simple changes to theappointment letter patients receive. This highlights that significantresource requirements are not always necessary to improve patientexperience.

As with any project of this type and scale there are limitations tothe methodology employed by the Service Pledge. For some breastunits, something that might have reasonably been consideredstraightforward to achieve has proved not to be. For example, at onehospital the information system did not allow for making anoutpatient appointment for people still classed as inpatients,resulting in the need to resort to operating a manual system inorder to fulfil the improvement goal to ‘ensure that all appoint-ments are pre-planned and pre-booked at every stage of patient’streatment’. Financial constraints are also pertinent and in somecases have resulted in protracted discussions around the practi-cality of some improvement goals. However, the Service Pledgemethodology uses a mix of short-, medium- and long-term goalsand feedback from Pledge Leads has highlighted that this is broadlythe right approach as it was perceived as good to get somethingachieved quickly, but there was also value in having targets thatstretched the team and allowed time to resolve any issues.

Securing patient involvement and service improvement inradiotherapy

Evaluation has shown the Service Pledge methodology is robustand can be applied to a wide range of treatment settings byproviding a framework to involve patients and building momentumand support for service improvement. Over the last few years it hasbeen recognised that significant improvements to waiting times andservice delivery in radiotherapy were needed.7,8 Whilst much hasalready been done to ensure a world-class service is developed anddelivered, continuous improvement and enhancement is requiredand the model could help radiographers deliver necessary change.

Improvement goals are essential because they providea tangible action as a result of patients voicing what is mostimportant to them. However, the wealth of information capturedthrough the patient surveys and interviews is as important andthere are a number of common issues that emerge. With radio-therapy being such a critical component of treatment for mostwomen with breast cancer, radiographers are ideally placed toaddress issues and tailor solutions specifically to their service. Forexample, unprompted improvement suggestions from patientsinclude: providing a separate exit or private room nearby to theconsultation or treatment room to enable distressed patients toleave with dignity, updating patients on the estimated length ofdelay for an appointment and the cause for delay, and providingenough chairs in waiting rooms to accommodate a friend or familymember accompanying patients. Patients also often want infor-mation about the possible side effects of their treatment and toknow what to expect next e “I would have liked a better under-standing of what to expect once treatment finished. I didn’t knowradiotherapy continued to work after the last treatment until thelast day. I didn’t realise it would continue to get worse and didn’texpect the extreme tiredness to go on as long as it has”.

Radiographers are often able to build meaningful relationshipswith patients due to the extended treatment period and thus areideally placed to lead patient involvement projects. Healthcareprofessionals are almost always seen as the main source of infor-mation and support for patients14 and some studies have shownthat patients place particular importance on achieving a sense ofemotional comfort during their treatment by forming relationships,

and want to obtain information to help reduce their fears andanxiety.15,16

Healthcare professionals involved in the Service Pledge modelhave also reported that patient views are often a powerful tool forsecuring change. In some breast units the value of involvingpatients has been less as a means of identifying areas needingimprovement and more as a mechanism to build momentum andsupport around addressing them, since, at an operational level, staffoften have a good understanding of issues and may have alreadytried to fix them. For example, trust senior managers involved inthe project have stressed the importance and value of involvingpatients and making changes based on their feedback, “the goalsidentified have made an improvement to the patient journey. Thefact they were identified with patients, through interviews andsurveys means that we are meeting patients’ expectations and theirneeds”.

Many of the healthcare professionals involved have also re-ported that working on the Service Pledge contributed to betterteam working: “.it helped unite us as a team. Hearing whatpatients had to say, discussing it together and agreeing on commonimprovement goals helped create a strong sense of sharedpurpose”. This is particularly pertinent for radiotherapy serviceslocated at a different location to where patients receive themajority of their care, which can result in difficulties in buildinga strong sense of team spirit.

With healthcare professionals needing to become ever morecommitted to patient experience and involvement, accessiblemodels like the Service Pledge can work across a range of diseaseareas and will be important to the delivery of gold standard care.Rooted in national standards, a major strength of the Service Pledgemodel is its flexibility in supporting those local service improve-ments that are relevant andmeaningful in each area. The article hasidentified limitations in the scope of the work to date and thepotential for utilising the model more widely in radiotherapyservices. Breakthrough Breast Cancer is committed to exploringopportunities to adapt it so that it can support all areas of breastcancer services and treatments, including radiotherapy.

Acknowledgements

The authors would like to thank all of the hospitals who have sofar taken part in the Service Pledge for the commitment they haveshown to listening to their patients and improving their experi-ences. The Service Pledge for Breast Cancer has been awardeda grant by the Department of Health’s Third Sector InvestmentProgramme: Innovation, Excellence & Service Development Fund.

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