Hospital Social Work Integrated

Care Pathway for Lung Cancer

Hospital social workers are represented to a greater or lesser degree in the holistic management of lung cancer. This care pathway identifies the stages of hospital social work input from pre-diagnosis to the final stage of management of the primary disease. The pathway demonstrates the extensive role that hospital social workers have in the management of the patients with lung cancer and their families. This intervention can occur in any setting, namely primary, secondary or voluntary care.

The nature of lung cancer means that a patient may see a social worker at any point from diagnosis onwards. The hospital social work care pathway is designed to be flexible and adaptive to each individual patient and their family’s needs. The pathway aims to promote a holistic approach to include the physical, emotional, psychological and spiritual needs of the patient, family and carers.

This document is broken down into two sections:

1. Care pathway profession specific interventions

2. Referral Criteria

It is assumed in all cases that informed consent has been requested and given for all assessment and interventions throughout the pathway. Similarly, accurate and timely record keeping and associated paperwork, attendance at multi professional meetings and inter disciplinary liaison will be assumed.

SECTION 1: CARE PATHWAY

1. Pre-Diagnosis/Diagnosis of Lung Cancer

At this stage the social worker may begin initial assessment to gather significant information about treatment and prognosis and prepare for patient/family contact.

The social worker will introduce themselves, if appropriate, to patient/family/carers, to explain their role and provide an information leaflet with details about the service and contact details.

2. Pre-Surgery/Surgery

Social workers in the Cancer Centre are unlikely to be involved at this time. If appropriate, the social worker will liaise with the relevant social worker/lung cancer specialist nurse in, for example, the Royal Victoria Hospital, or wherever the surgery has been undertaken to pass on and receive relevant information.

3. Radiotherapy and adjuvant treatment – curative/palliative

The patient may or may not have been previously known to the social worker at this point in the process. It could, however, be the first contact and first attendance at the Cancer Centre.

The social worker will introduce themselves to the patient and family members/carers, outlining the social work role and providing contact details. They will be gathering information and undertaking a comprehensive assessment of need – considering both practical and emotional needs of the individual and family members.

On a practical level, following holistic assessment, the social worker may be liaising with community services to organise or increase service provision, signposting re benefit and housing advice and undertaking application of grants.

On an emotional level, the social worker may provide support to the patient, family member or carers re impact of diagnosis, ability to cope and managing side effects and planning for future care needs.

In the case of abnormal grief reaction or need for in-depth counselling the social worker may refer to psychology/counselling services.

4. Chemotherapy – curative/palliative

There is a greater opportunity to engage and build relationships with the individual and also with other family members who are on the ward or attending for outpatient treatment. Support can be both practical and emotional.

Practical support involves preparation for discharge planning and assessment of services to maintain quality of care. Liaison with multi-disciplinary colleagues to undertake assessment is also important. Co-ordination of assessments and referral to care management may be necessary.

Emotional support involves helping the individual and family members cope with current treatment and side effects while addressing possible implications for the future.

5. Hospital Discharge Planning

The social worker works with the individual and their family to ascertain their wishes. Following the co-ordination of multi-disciplinary assessments, the social worker completes a social care or care management assessment to organise an assessed package of care, as needed, on discharge.

The social worker often needs to negotiate and mediate with differing family requests and advocate on behalf of the patient with community services to recommend practical or emotional support on discharge.

6. Follow-up: Post Cancer Treatment

In general, issues at this stage would be the responsibility of services in the community. Where appropriate the hospital social worker will refer to community colleagues for services. The hospital social worker would also provide follow-up, where required, at review appointments as circumstances may change.

7. Supportive Palliative Care and End of Life

Social workers in the Cancer Centre would be involved where the individual is an inpatient. Intervention may be to offer emotional support to the patient or family. At this time social workers can assist in facilitating good communication between patient and family members.

Where required the social worker would provide a family with booklets and advice about how to talk to their children and if needed would complete individual work with the child or young person.

This may also be the time that practical support is required in relation to signposting for will making, assistance regarding funeral arrangements and expenses and application for grants.

8. Bereavement

The social worker may carry out a post bereavement visit or telephone contact and if appropriate, attend the funeral. The social worker may offer continued emotional and psychological support to families and carers where required.

Evidence Base

Hospital Social Work affords access to populations already experiencing profound ill-health not already known to community Social Services Department but who are in need of services to prevent further suffering or further deterioration of health (McLeod, E; The Strategic Importance of Hospital Social Work, Social Work, and Social Sciences Review, 6 (1) 1995 pp 19-31.

There is much evidence to reflect that Hospital Social Work is cost-effective and can reduce overstays in hospital (Boone, Coulton and Keller, 1981; Connor, A and Tibbit, J E (1998); these studies demonstrated that hospital days could be saved with the intervention from Hospital Social Workers.

In a paper published (November 2006) by the Joseph Rowntree Foundation regarding service user’s views of specialist palliative care social work, it is stated that.. “Service users overwhelmingly valued their experience of Specialist Palliative Care Social Workers, highlighting the quality of the relationship between service user and Social Worker, the personal qualities of the Social Worker and the nature and process of the work with them. Service users appreciated the wide range of support Social Workers offered, including counselling and advice, practical help, advocacy, individual and group work”.

The National Institute for Health & Clinical Excellence (NICE) has issued guidance on how healthcare services for adults with cancer should be organised ( (August 2005) and they recommend that there should be Multi-disciplinary Teams.

The Hospital Social Work Service (BHSCT – South East area) retains its ‘legacy’ Mission Statement:

“To provide a comprehensive, high quality, effective and responsive service: though:-

  • The delivery of a caring patient.
  • Provision of a patient-centred service.
  • Responding sensitively to need.
  • Adopting a holistic approach.
  • Working in partnership with patients, carers, hospital staff and community staff.
  • Empowering patients to stay in control of their lives during diagnosis, treatment and hospital care.

Professional social work staff are required to meet professional standards and work within a statutory framework of legislation (see legislative context section). Hospital social work staff additionally undertake work within its own Practice and Management Standards.

Legislative Context

  • Safeguarding Vulnerable Adults: Regional Adult Protection Policy and Procedure Guidance, September 2006.
  • Protection of Children and Vulnerable Adults (NI) Order 2003
  • Quality Improvement & Regulation (NI) Order 2003
  • Carers & Direct Payments Act (NI) 2002
  • Northern Ireland Act 1998 (Section 75)
  • Human Rights Act 1998
  • Disability Discrimination Act 1995
  • Children (NI) Order 1995
  • Carers (Recognition and Services) Act 1995
  • Community Care Order (NI) 1992
  • NHS & Community Care Act (1990)
  • Disabled Persons (NI) Act 1989
  • Mental Health (NI) Order 1986
  • Chronically Sick & Disabled Persons (NI) Act 1978
  • Health & Social Services (NI) Order 1972 (and subsequent orders)

SOCIAL WORK DEPARTMENT

for

ONCOLOGY AND HAEMATOLOGY

(CANCER CENTRE, BRIDGEWATER SUITE AND HAEMATOLOGY DEPT)

REFERRAL PROTOCOL

Please Refer to Referral Criteria.

Ensure patient consents to referral (except where statutory duty permits consent to be overridden).

Referrals can be made in person to the relevant social worker (See Appendix 1) or

by telephoning the Social Work Department on Ext 3600.

Referrals should include the following information:-

  • Patient’s Name
  • Patient’s Home Address
  • Patient’s Date of Birth
  • Patient’s Next of Kin
  • Patient’s GP
  • Patient’s Primary Diagnosis
  • Patient’s Consultant
  • Patient’s Location ie. Ward, BWS, Out Patient Clinic, XRT Dept, etc
  • Reason for Referral (as per Referral Criteria)
  • Patient Aware of and Consenting to Referral
  • ‘Expected Date of Discharge’ (if appropriate).

SOCIAL WORK DEPARTMENT

for

ONCOLOGY AND HAEMATOLOGY

(CANCER CENTRE, BRIDGEWATER SUITE AND HAEMATOLOGY DEPT)

REFERRAL CRITERIA

The following patients should be referred to the Social Work Department:-

  • Patients who need discharge planning for social care needs.
  • Patients whose carers and / or family members are under acute pressure because of the impact of the illness.

This may include patients who are carers of dependent adults.

  • Patients whose family relationships are under acute pressure because of the impact of the illness.

This may include empowering patients in the support of their children through each stage of their illness, eg. Pre-bereavement work.

  • Patients who are socially isolated and lack adequate community support to meet their needs.
  • Patients who would benefit from emotional support.

This recognises that while it is ‘normal’ to be anxious, some patients may benefit from social work support.

  • Patients who are thought to be vulnerable and / or may be at risk.

Eg. Children, Adults, Elderly, (This work is dealt with under Regional Procedures).

  • All Patients who are under 21 Years of age should be referred to the Social Work Department.
  • Patients who are experiencing financial pressures as a result of their cancer illness.

This may include information with respect to possible Grants and Health Related Benefit entitlements.

SOCIAL WORK DEPARTMENT

for

ONCOLOGY AND HAEMATOLOGY

(CANCER CENTRE, BRIDGEWATER SUITE AND HAEMATOLOGY DEPT)

MISSION STATEMENT

Our purpose is to:

  • Provide a person centered social work service to Users
  • Support, guide and provide advice for Service Users and their Carers, through their journey at the Northern Ireland Cancer Centre or Belfast City Hospital.

We are a hospital based service that:

  • Is Service User and Family Focused
  • Provides practical and emotional services to Patients and their Carers
  • Offers information and advice
  • Can act as a facilitator of communication between parents and their children
  • Acts as an advocate for the Patient and their families
  • Acts as a link between the hospital and the community providers of care.

How do I contact a social worker?

  • You can ask any member of the hospital staff to contact a social worker for you

You can contact a social worker yourself by phoning (028) 9026 3600.

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