Ministry of Public Health

Getting the right treatment is vital, but it must be supported by ongoing care. The growing prevalence of cancer, coupled with the greater number of survivors is increasing pressure upon follow up services. The current model of care centralizes cancer patients into secondary and tertiary care, but once treatment is successful, or even in between treatment, community and primary care services need to be fully incorporated into an integrated care pathway, allowing patients to be supported irrespective of where they are in the pathway.

Some progress has been made to develop interventions to support people living with and beyond cancer. This in cludes the establishment and evolution of the mobile healthcare service, bringing more advanced care into people’s homes and work by PHCC to develop a model of community nursing to support the family medicine model. HMC has also invested significantly in palliative care services however there are still significant gaps in the patient care pathway. Improving community services to enable cancer patients and survivors to continue to be effective and productive members of their families and

community, is an essential goal for both the NHS 2017 - 2022 and for the improvement of cancer services across t he country.

The movement of patients through the pathway is often refe rred to as ‘transitions of care’. There is a need to clearly define what and whom this encompasses from a patient, healthcare professional and system perspective. It is essenti al that the key Domains of transitional care include

risk stratified follow-up, transition between services (i.e. ped iatric to adult services) and the management of longterm effects of cancer or its treatment.

Priorities

Develop Risk Stratified Transition Care Pathways

In May of 2016, healthcare professionals working with cancer were asked how the growing population of cancer survivors in Qatar could be most effectively assisted with returning to normal life. An indicative 85% said that funding community based, physician-led or survivor-led programs would be most effective in the ongoing management of these patients.

It is therefore recommended that Qatar establish programs to support and educate cancer survivors, with a clear program to identify champions, supporting their communities and those with cancer.

In recognition of thi s significant agenda for change, MOPH will lead in the development of a National Transition Framework. A team of cross stakeholder professionals, in consultation with patient representatives and the QCS, will firstly define the program of work to include models of follow-up care, clinical pathways between services and agree the management of long-term effects. The NCAGs will have an essential role in the development of this

program, as the needs of each cancer site will be different. The adoption of health lifestyle goals, articulated in Do main 2 are also of great significance in the development of the Transition Framework. There is increasingly strong evidence supporting the long-term benefits of exercise programs for survivors in secondary prevention and improving quality of life measures, and therefore should be a central focus of ongoing care programs.

The Framework will seek to ensure a pathway of care across all clinical service and organizational boundaries, public and non-public services. Care plans, self-management, improved access to care, evidence based lifestyle and surviv orship support systems to increase healthy living will all serve to enhance quality of life for survivorship. Treat ment summaries at the end of primary treatment will be important for primary care providers to support monitoring and recognition of late effects or recurrence. It will also be necessary to enhance access to counselling and psychological support, in primary care which can in clude the development of support groups for site specific tumours.

It will be essential that all outpatient ongoing care services are developed in alignment with the ongoing implementation of the family medicine model across PHCC centres.

The Family MedicalModel (FMM) PHCC

Family medicine is the health care specialty which provides continuing and comprehensive health care to individuals and families, integrating biological, clinical and behavioural sciences. Its scope encompasses all ages, genders, every disease entity and each organ system.24 The Family Physician is broadly educated in the family practice medical specialty. They possess unique attitudes, skills and knowledge which qualify them to provide continuing and comprehensive medical care, health maintenance and preventative services to all family members regardless of the age, gender or type of problem the individual presents.

The range of services available at a FMM health centre will be divided into three broad categories, but in

general will either be:

Foundation services: essential and integral components of any primary health care service, which should be delivered by the core FMM interdisciplinary team and considered family medicine’s full range of services and scope. Foundation health center services are provided by the primary care interdisciplinary core team and can be integrated in a team approach.
Health center-based services: still considered as fundamental primary care services. However, due to demand, resources or required expertise are stretched, but are available to all of the health center teams.These might also comprise additional services required to meet the needs of the registered patient populationand community.
Regional services: considered important to high quality primary care services, but are not required in each and every health centre, but rather will be offered regionally, through internal referral protocols. Service provision for more specialized services that are not needed per health centre will take into account a hub and spoke method of delivering regional services from larger, centralized health centres with clear patient referraland dis charge pathways in place.

Develop patient-centredend o f life care

End-of-life care “helps all those with advanced, progressive, incurable illne ss, to live as well as possible until end of life. It en ables the supportive and palliative care needs of both p atient and family to be identified and met throughout th e last phase of life and into bereavement. It includes m anagement of pain and other symptoms and provision of psychological, social, spiritual and practical support”.

In 2014, the NCCCR opened the 10-bed supportive and pall iative care unit, which provides a tranquil environment, con ducive to providing end of life care. However, not all pa tients will need, or want to be treated on an inpatient ba sis and in some instances, could be better cared for at home. To support this, the NCCCR has collaborated with the mobile healthcare service to provide end of life care within the home. The NCCCR is currently supporting the

education and development of palliative care skills and knowledge for the mobile healthcare service nursing staff and this is recommended to continue.

When healthcare professionals at the forum in May 2016 were asked, “What would you consider to be the best setting for delivering excellence in end of life care / palliative care?”, it was revealed that delivering supportive end of life care can and should be delivered in different settin g s. The results showed that 42% reflected that home would provide the best setting, 35% said a community type hospice and 25% would advocate specialist hospital based palliative care.One of the most important factors in developing supportive care is clearly understanding the needs of patients and their families. International literature review suggests that the common factors, which are important to patients and families at the end of life, include:

Symptom management
Preparation for the end of life
Spiritual care
Good relationships between patients
Family members
Healthcare providers

This evidence is applicable to the local context and it is the refore recommended that work be undertaken to understand and agree the principles of end of life care for Qatar. The WISH End of Life report published in 2013 indicates international principles of ‘how to die well’, which can be viewed in the development of Qatar’s own principles for end of life care.

In addition to this, attention should be paid to the ongoing development of good communication skills for healthcare providers, as well as ensuring the ongoing development of skills required to accurately diagnose dying symptoms. Consideration should also be given to the development of advanced care planning tools for those approaching the end of life.

The WISH End of Life report also highlighted the five steps which can dramatically improve end of life care.It is recommended that the five steps underpin the future development of supportive care services in Qatar. The avoidan ce of maximal treatment, the adoption of patient a dvanced care directives on end of life decision making and the adoption of the WHO list of essential medicines and the elimination of overly restrictive regulation have been highlighted as key objectives in the delivery of excellent supportive and end of life care for patients. It is im portant to note that to support this initiative, collaboration and partnership must be developed with organizations already providing similar services in Qatar or internationally. While being cognizant of the needs of the Qatari population and its cultural imperatives, it is important not t o over-medicalize all elements of the pathway and

encourage participation from nongovernmental organizations.

5 Steps to Improve End of Life Care

STEP 1: MAKE CARE OF THE DYING A PRIORITY FOR ALL

Produce a national strategy for end-of-life care.
Include palliative and end-of-life care as part of healthcare for all diseases.
Monitor the scale and need for end-of-life care locally.
Sign the Prague Charter and recognize that access to palliative and end-of-life care is a human right.
Set up a national initiative using online tools and innovative campaigns to encourage people to learn andcommunicate more about death and dying.
Encourage the use of advance care directives, so that patients can make their own end-of-life wishes andexpectations known beforehand, rather than under pressure at a time of crisis.

STEP 2: REDUCE UNNECESSARY SUFFERING

Adopt the WHO Model List of Essential Medicines and eliminate overly-restrictive. regulations banning the use of opioids for palliative and end-of-life care.
Ensure essential medicines are nationally available in central medical stores, licensed appropriately,and distributed effectively through existing distribution channels where possible.
Ensure the appropriate use of opioids and other essential medicines.

STEP 3: IMPROVE KNOWLED GE AND USE DATA TO DRIVE INNOVATION

Invest in research and development in palliative and end-of-life care.
Form partnerships between national, regional, and international palliative care organizations to carry outre search and publish high-quality reports.
Capitalize on knowledge gained from research outcomes to lower costs and improve care.
In places where Western medicine has not been fully adopted, engage with traditional healers to improve end of life care.

STEP 4: MAXIMIZE RESOURCES

Engage the local community in end-of-life care.
Utilize telemedicine and technology-based innovations to improve access to end-of-life services, especially in ruraland re mote areas.
Empower patients through better access to knowledge about end-of-life care choices and availability.

STEP 5: IMPROVE SKILLS

Include palliative and end-of-life care training in all professional healthcare undergraduate and postgraduate programs.
Include bereavement support in palliative and end-of-life care training programs.
Share global learning to enable all countries to build palliative and end-of-life care services.
Access or develop e-learning training modules for staff and volunteers.

Program Activities:

Ongoing Care	Lead
Develop and implement National Cancer Transition Framework: Develop models of follow-up care Develop pathways for transitions of care Guidelines for management of long-term effects of cancer	MOPH
End of Life care	Lead
Continued development of end of life care service provided between NCCCR and Mobile Health Service	HMC
Develop and publish principles and guidelines for end of life care in Qatar	MOPH

Ongoing Care