The Newham community-based prostate clinic was aimed at supporting the healthcare needs of men from hard-to-reach groups who often feel excluded from accessing healthcare support.
Based in an African and Caribbean Community Centre, the clinic attempted to map itself onto the needs of the service user rather then the other way round. Men could self-refer and did not need an appointment to attend; opening hours were flexible and specialist nurses and doctors provided a one-to-one service providing information and support about all aspects of prostate health. Following on from a consultation service users could access diagnostic investigations on site with a follow up in Secondary Care if necessary. Blood could be taken for PSA testing in clinic and the test carried out in the Acute Trust.
Of those who had a consultation:
Of the 98 per cent who had a prostate consultation:
Of the 59 per cent referred into Secondary Care 5 per cent (n=3) were diagnosed with other complications including urinary retention, diverticulitis and epididymal cyst (requiring surgery).
Prostate cancer is the second largest cancer in men and worldwide incidence has increased.
Research has shown that the incidence is three times higher in African Caribbean men and that as a group they are also less likely to access appropriate healthcare for a variety of reasons (lack of knowledge regarding disease and symptoms, lack of understanding of the NHS or mistrust of large statutory bodies).
The Cancer Reform Strategy identified community-based Prostate Health Clinics as a possible vehicle for improving access, support and strengthening knowledge and decision-making regarding treatment.
The borough of Newham in East London has one of the most diverse populations in England and includes a high proportion of black men. There are considerable health inequalities within Newham in terms of location, gender, level of deprivation and ethnicity. For example, life expectancy of men and women from the most deprived group is four years shorter than those in the least deprived group.
Further, the experience of cancer patients living in London was reported as poorer when compared with those living elsewhere in the 2010 National Cancer Patient Experience survey. It has also been identified that those from black and minority (BME) ethnic groups a poorer patient experience then those from non-BME groups.
Newham Hospital Trust also scored poorly in the National Cancer Patient Experience survey when compared with other Trusts (both in London and across England).
On this basis, Newham was identified as a strong location for establishing a pilot prostate health clinic to support the local population and explore the effectiveness of the model. In Spring 2009, Dr Frank Chinegwundoh submitted an expression of interest to the Department of Health to host a pilot clinic in Newham. The bid was successful and the pilot clinic ran in Newham from December 2010 to December 2011.
There were specific DH critieria that the pilot was required to support. These included:
In addition the local project team identified a key number of outcomes to be achieved. These included testing out if the clinic was able to:
In addition the project team wanted to assess the practicality of delivering the clinic in terms of:
The community-based prostate health drop-in clinic (CBPHDIC) was a multi-agency, multi-organisational project involving the following stakeholders:
The design and delivery of the project was supported by a variety of organisations from different backgrounds and healthcare settings. Each agencies representative’s had a differing skill sets that contributed to the overall development of the project and helped keep it client focused.
The location and setting of the clinic was vital: it needed to be accessible, user-friendly, professional yet informal, easy to set up, well identified within the local community and support a ‘drop-in philosophy’ that promoted self referral.
Originally West Ham Football Club was approached and although supportive of the project were not able to commit in the long term. The second venue identified was the African and Caribbean Community Centre in Newham, which proved to be an extremely strong choice and fitted with the project aims of the DH and supported a number of the local priorities. Funding for the community centre was accessed from the PCT.
The clinic ran a multi-professional model involving a consultant, specialist registrar, a number of clinical nurse specialists (CNS) and a receptionist. The consultant was the clinical lead for the pilot and the major project champion. Nurse specialists, who provided support, leadership and coordination, led both clinical management and operation.
The pilot involved the Prostate Cancer UK (PCUK) from the very early stages. It was part of the steering group and was able to provide expertise, constructive feedback and financial support to the pilot. Local groups (BME men affected by prostate cancer) were accessed via the charity. The groups helped promote and publicise the clinic and targeted areas where men gathered.
Originally the bespoke pilot planned to offer a one-stop clinic providing clinical assessment, digital examination, urodynamic investigation and on-site PSA testing. However, during the planning phase there were a number of issues raised relating to on-site PSA testing and subsequently testing was provided in Secondary Care (although blood was taken at the clinic).
To help with the evaluation of local outcomes and to provide support with economic modelling (cost and sustainability) Kings College, London was commissioned to evaluate the Prostate Cancer Clinic, led by Professor Emma Ream and her team.
Kings College, London was involved very early on in the planning stages of the pilot and a bespoke evaluation programme was developed that married up with the identified objectives of the pilot. Members of Kings College, London also joined the steering implementation group, which improved communication and maximised effective working practice.
Advertising the clinic
The communication team at Newham University Hospital NHS Trust and the marcomms team at Prostate Cancer UK joined forces to promote the pilot. A blended approach was used that involved radio (interviews with the lead clinician) posters and flyers, advertisements in the local paper, posters on the inside and back of local buses, articles in hospital newsletters and the local magazine. There were two media campaigns, a large one from December 2010 – May 2011 and smaller ones in September 2011 and December 2011.
Some 47 per cent of those attending the clinic said that they had heard of the clinic through advertising, with some advertising working better than others: the bus advertising campaign appeared to have had a limited effect while articles in the Newham Recorder produced a much bigger response among men. This had implications for future health promotion campaigns and the associated budget – there was a cost attached to advertising on buses, but local press articles were free and in this case more effective.
Almost 25 per cent (n=74) of men heard about the clinic from other men. One of the positive outcomes of the project was that men were talking about the pilot to their friends and peers in the community and recommending it. This showed that they will access healthcare services through personal recommendation and is something that needs to be considered for future health programmes.
The walk-in Community Prostate Clinic at the Newham African and Caribbean Community Centre was operational from December 2010 until December 2011. It opened on a Monday and Tuesday from 14:00 – 19:00 (enabling men to attend outside, standard business hours). It opened for a total of 98 days.
During this time, 328 men attended of which 98 per cent (n=322) had a consultation about prostate cancer while the remaining individuals used the clinic to access information.
The number of clinic attendees ranged between 0 and 15 with a median number of three. Neither the Monday nor the Tuesday appeared to be more popular then the other. Most men preferred visiting the clinic in the afternoon (n=175, 65 per cent) although a third of men of working age did opt to attend in the evening slot (n=93, 35 per cent), demonstrating the need for offering flexible hours to this client group.
Of those attending, 70 per cent came due to urinary symptoms or to have a ‘check up’. Of the sample 55 per cent complained that they had urinary symptoms but had not presented to their GP to have them investigated. The reasons for this ranged from not thinking the symptoms were serious enough, to being too worried to attend, to a lack of satisfaction with the GP service or symptom embarrassment.
Of those who had a consultation 271 (84 per cent) opted to have a PSA Test, 237 (74 per cent) had a digital rectal examination (DRE), 181 (56 per cent) had their urine flow rate assessed and 169 (52 per cent) had a bladder ultrasound for residual volume.
Of the 98 per cent who had a prostate consultation almost 20 per cent (n=59) were referred to Secondary Care for urinary symptoms and/or prostate enlargement that required further examination.
Of those referred into Secondary Care 15 per cent (n=9) were diagnosed with prostate cancer, the majority with local disease.
An unintended consequence of running the clinic was the diagnosis of pathologies other than prostate cancer. Of the 59 per cent referred into Secondary Care 5 per cent (n=3) were diagnosed with other complications including urinary retention, diverticulitis and epididymal cyst (requiring surgery).
Postcode data (using deprivation scores) showed that the men who had a consultation with clinic staff were typically living in highly deprived areas: 75 per cent were living in localities classified within the fifth quintile (most deprived).
Men attending who had a consultation were asked to report on their knowledge of prostate cancer (risk factors, symptoms and screening tests) on arrival at, and before leaving the clinic. This determined that clinic attendees had poor levels of knowledge regarding prostate cancer and very poor knowledge about PSA testing when presenting at the clinic. Following the clinic attendance men’s knowledge of prostate cancer, symptoms, and diagnostic tests was enhanced.
In depth interviews with a sample of 20 men who had used the clinic found high service user experience scores in relation to clinic accessibility and suitability: 100 per cent (n=292) of men asked said they would recommend the clinic to others while 83 per cent (n=237) said that they were very satisfied with their visit.
As a pilot the clinic proved to be a success with its intended audience (African and Caribbean men) who tend not to access healthcare services for a variety of reasons.
Men were happy to self-refer to the clinic independently and suggest it to their friends and colleagues. A quarter of men heard about the clinic by word-of-mouth suggesting that BME men do share healthcare stories with one another and will in some instances refer healthcare agencies to friends.
Nine men were diagnosed with early stage prostate cancer and an unintended consequence of the clinic was the diagnosis of other disease conditions.
Nine men using the clinic scored high levels of satisfaction for accessibility and convenience and considered the clinic ‘male friendly – a factor that encouraged attendance. All of the men asked would refer the clinic to others.
Despite having urinary symptoms men chose not to go to their GP, citing a number of reasons from not thinking the symptoms were serious enough to being too worried to attend, to feeling embarrassed or being unsatisfied with the GP service. These men did attend the clinic and did refer themselves suggesting that alternative health models may have a place in supporting hard to reach groups.
Kings College, London carried out the evaluation using a variety of methods including:
It was important to understand from an economic perspective whether the community clinic pilot was a viable alternative healthcare model that could be replicated cost effectively elsewhere, or simply a costly bespoke programme that (while scoring very highly in user satisfaction) was simply unaffordable.
Costs were broken down by equipment, workforce, media and clinic hire. This was then divided by the number of men attending (n=322) – the cost per man per session was calculated at £282.72. If the clinic had run at full capacity (target number men per clinic = 12) then 1176 men would have been seen in a year bringing the consultation cost down to £77.41. As a GP consultation is around £36 then this would have compared favourably as extra tests not available at a GP practice were also being carried out.
Breaking costs down by diagnosis reveals a cost of £10, 115 per man per prostate cancer.
It is possible that these men would not have presented to their GP until very late in their disease pathway (if at all) and may have needed more complex treatment or palliation at a greater cost per head.
Further savings would have been made if the pilot had run for another two years as the start up equipment had already been purchased (£23,551.63).
Other smaller savings would have been made in years two and three as expensive parts of the advertising campaign that had not worked (posters on buses) would have been dropped in favour of other more successful (and inexpensive) programmes
Macmillan Network Nurse Director
North East London Cancer Network