Prostate Cancer UK recently reported that there is an impending crisis for men with prostate cancer, simply because the number of nurse specialists available is insufficient for their needs [1].
Background
As has been widely reported, the incidence of prostate cancer will continue to increase over the next 10 years, and it is expected to become the most commonly diagnosed cancer by 2030 [2].
Alongside this, Prostate Cancer UK’s audit of almost 100 prostate cancer clinical nurse specialists (CNS) found that 41% plan to retire in the next 10 years [3]. At the same time the workload will be increasing, not only because of the rising incidence of prostate cancer, but also from the 11% improvement in prostate cancer mortality rates over the past 10 years [4] which entails a growing number of appointments or contact episodes for the required continued follow-up and care.
There is also evidence that the existing workforce is already overstretched with many CNSs working beyond their contracted hours [3]. To compound this problem, current nursing and midwifery vacancies in the UK are estimated to be at around 1 in 12 posts (8%) with some trusts having vacancy rates of up to 12% [5].
This chimes with my own experience, as it has taken 12 months to replace a urology CNS who left our team, having advertised and interviewed for the role on three occasions. These posts are difficult to fill, as they require in-depth knowledge of the disease, appropriate clinical experience and often a master’s degree – not to mention an interest in the field and patient group [6].
In my experience it also takes 12-24 months for a CNS to become a fully autonomous practitioner, thus adding further pressures to the rest of the team during these transitions.
Perception of the role
Some might say, “so what if there aren’t enough CNSs?” Looking through the comments attached to the Mail on Sunday coverage of Prostate Cancer UK’s survey finds some unsurprising remarks which reflect a degree of scepticism I have occasionally seen in patients [7]:
“My mind is racing...how does access to nurses improve men’s sexual dysfunction?”
“I’d prefer more doctors tbh.”
“You are overstating what nurses can do to help resolve the postoperative effects of prostate cancer.”
It would appear that there remains work to be done in gaining recognition as to the value of clinical nurse specialists and the role that they play in cancer care. This value needs to be recognised, not only by the public but also by employers. Clearly, if a workforce is not seen to offer value it is unlikely that anyone will invest in it.
There is some suggestion, within Macmillan’s last census, that CNS posts have been downgraded from Band 7 to Band 6 at the point of recruitment or even within contract. This is perhaps a wider issue in Scotland, with 50% of Scottish respondents to a survey graded at Band 6, whereas the majority of respondents from elsewhere in the UK were graded at Band 7 [8].
What does a nurse specialist add?
The CNS role has been described as “working as part of a multidisciplinary team and in partnership with patients and carer to plan, deliver and evaluate individualised care focused on facilitating health and enhancing well-being” [9]. The National Cancer Action Team suggest that the CNS makes several key contributions to cancer such as [10]:
- Acting as a key worker across the patient’s whole pathway.
- In-depth knowledge of the tumour area.
- Ability to assess patients’ holistic needs.
- Advanced communication and advocacy skills.
- Excellent decision-making abilities.
- Leadership within the MDT and wider cancer team.
From a patient perspective these are all very important and certainly appear to be valued by them. It has been reported that men diagnosed with prostate cancer often have unmet needs and higher levels of anxiety, often related to the particular decision-making process they may have to go through [11]. However, this distress can be reduced by a good relationship with a CNS, as they are best placed to give good information and often act as a conduit between patient and consultant [11]. This is especially important given that patients are often not keen to directly contact consultants themselves.
“It would appear that there remains work to be done in gaining recognition as to the value of clinical nurse specialists and the role that they play in cancer care”
From an NHS perspective CNSs have been estimated to reduce emergency hospital admissions by 10%, as well as reducing stays in hospital by up to three days. This could save hospitals £104 million each year, as well as being of significant benefit to patients who spend less time in a hospital bed and more time in their own home [10,12]. It has been estimated that the overall saving of a CNS running a clinic versus a consultant is £100,000 per annum [13]. This also frees up significant time for consultants to see new patients whilst maintaining continuity of service.
Moving forward
So, what can we do to improve the service provision as we go forward into increasing demand and potentially increasing retirements? More investment is key, but that is easier said than done in an NHS where budgets are increasingly stretched. Better succession planning could also help in principle, but often posts can’t be advertised until the incumbent has moved on and the budget is freed up. Even if you could pre-advertise, the lead time from appointment to independent practice is considerable. To my mind it can often seem easier to find money for a consultant post than it does a CNS, so perhaps a defined ratio of CNSs to consultants would help to address this.
Innovations such as Prostate Cancer UK and Movember’s new ‘supported self-management approach’ can also help. This gives men control of their own care through an easy-to-use online portal, freeing vital NHS time and resources while maintaining or even improving outcomes for the men involved [14].
Conclusion
My hope is that NHS providers across the UK will take note of the major issues highlighted by Prostate Cancer UK’s survey and take urgent action both to increase nurse numbers and reduce the excessive burden on current nurses. If they don’t, it’s clear that thousands of patients will miss out on the support they need.
References
1. Prostate Cancer UK Survey. Commissioning Clinical Nurse Specialists: diagnosis, treatment and beyond. 2019.
https://prostatecanceruk.org/media/
2498754/making-the-case-for
-clinical-nurse-specialists
-aug-2019.pdf
[Accessed 2 October 2019].
2. Orchid. Prostate Cancer: The state of the nation. 2018.
https://orchid-cancer.org.uk/
wp-content/uploads/2018/04/
April-2018-Report-Spread-2.pdf
[Accessed 4 September 2019].
3. Prostate Cancer UK. Making the case for clinical nurse specialists. 2019.
https://prostatecanceruk.org/
media/2498570/5626-cns-survey.pdf
[Accessed 4 September 2019].
4. Mayor S. Latest UK figures show increase in prostate cancer diagnoses and falling death rate. BMJ 2012;344:e3252.
5. Rolewicz L, Palmer B. The NHS workforce in numbers: facts on staffing and staff shortages in England. Nuffield Trust. 2019.
www.nuffieldtrust.org.uk/resource/
the-nhs-workforce-in-numbers
[Accessed 6 September 2019].
6. Henry R. The role of the cancer nurse specialist. Nursing in Practice 2015.
www.nursinginpractice.com/
role-cancer-specialist-nurse
[Accessed 2 October 2019].
7. Wardle S. Thousands of men could be left to face the effects of prostate cancer alone due to a shortage of specialist nurses, charity warns. Mail on Sunday 24 August 2019.
www.dailymail.co.uk/health/article
-7390631/Prostate-cancer-crisis-shortage
-specialist-nurses-charity-warns.html
[Accessed 3 September 2019].
8. Pushon G, Endacott R, Aslett P, et al. The experiences of specialist nurses working within the uro-oncology multidisciplinary team in the United Kingdom. Clinical Nurse Spec 2017;31(4):210-18.
9. Knowles G. Advanced nurse practice framework – Cancer nurse specialist framework. Scottish Executive; 2006.
http://aape.org.uk/wp-content/
uploads/2015/02/ADVANCED
-PRACTICE-FRAMEWORK
-Scottish-AUG-2006.pdf
[Accessed 2 October 2019].
10. NHS National Cancer Action Team and Macmillan Cancer Support. Quality in nursing. Excellence in cancer care: The contribution of the clinical nurse specialist. 2010.
www.macmillan.org.uk/documents/
aboutus/commissioners/excellencein
cancercarethecontributionofthe
clinicalnursespecialist.pdf
[Accessed 6 September 2019].
11. Barrasin E, Appleton D. Patients’ experiences of the uro-oncology clinical nurse specialist: the value of information giving. Cancer Nursing Practice 2018;17(3):25-29.
12. Macmillan Cancer Support. Cancer Workforce in England: A census of cancer, palliative and chemotherapy speciality nurses and support workers in England in 2017. 2017.
www.macmillan.org.uk/_images/
cancer-workforce-in-england-
census-of-cancer-palliative-and-
chemotheraphy-speciality-nurses
-and-support-workers-2017
_tcm9-325727.pdf
[Accessed 2 October 2019].
13. Oliver S, Leary A. Return on investment: workload complexity and value of the CNS. British Journal of Nursing 2012;21(1):35-6.
14. Frankland J, Brodie H, Cooke D, et al. Follow-up care after treatment for prostate cancer: evaluation of a supported self-management and remote surveillance programme. BMC Cancer 2019;19(1):368.
Declaration of competing interests: None declared.
