The Development of Ambulatory Cancer Care in the UK: A Scoping Review of the Literature

Finch, Alison; Cooper, Silvie; Raine, Rosalind; Taylor, Rachel M.; Gibson, Faith

doi:https://doi.org/10.1155/2023/4589362

European Journal of Cancer Care

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Abstract Introduction Background Methods Results Discussion Conclusion Data Availability Disclosure Conflicts of Interest Acknowledgments Supplementary Materials References Copyright Related Articles

Review Article | Open Access

Volume 2023 | Article ID 4589362 | https://doi.org/10.1155/2023/4589362

The Development of Ambulatory Cancer Care in the UK: A Scoping Review of the Literature

Alison Finch,^1,2Silvie Cooper,¹Rosalind Raine,¹Rachel M. Taylor,²and Faith Gibson^3,4

Academic Editor: Liren Qian

Received31 Jan 2023

Revised07 Mar 2023

Accepted15 Mar 2023

Published20 Jun 2023

Abstract

Introduction. Ambulatory Care (AC), where patients receive inpatient cancer treatment on an outpatient basis, was introduced into the United Kingdom (UK) National Health Service (NHS) in 2004. Although now well established within some services, the development of AC across the NHS is yet to be described. We report findings of a scoping review that set out to understand the provenance of the clinical pathway, whilst exploring drivers for the development of AC in the UK. Methods. Using scoping review methods, database citation, and grey literature, searches were undertaken to map the storyline of AC’s development internationally. The Joanna Briggs Institute guidance was followed; this included consultation with six professionals considered critical to the development of AC. Results. From the 57 records identified between 1979 and 2022, four domains were identified through a narrative synthesis that reflected the following drivers for AC: financial; optimisation of bed capacity; advances in technology and supportive care; and professional motivation to improve patient experience. Conclusion. We report the first descriptive analysis of the international development of AC, locating the UK cancer service within its commissioning, operational, and philosophical foundations. The review additionally highlights limited research exploring the experience of the AC model from the patients’ perspective.

1. Introduction

Cancer care is an evolving specialty. Advances in treatment, technology and supportive care have helped foster greater opportunities for self-care, and many protocols that a decade ago would have required hospital admission can now be given on a daycare or ambulatory basis. Within healthcare contexts globally, the term Ambulatory Care (AC) typically refers to an outpatient service. In the United Kingdom (UK) cancer context, it denotes the hospital-led coordination and delivery of cancer treatment on an outpatient basis that would, throughout the National Health Service (NHS), usually require inpatient hospitalisation. What this means is that many cancer patients now experience much of their care in a hotel or residential setting, and this is thought to be conducive to better patient experience. These ambulatory pathways also help meet increasing service demand. Although now well established as a clinical service within the NHS, a more comprehensive narrative on the development of AC within NHS cancer services has yet to be reported. This has limited the potential for shared learning, with different services beginning to develop AC practice in relative isolation from one another. In a new contribution to the AC literature, this paper reports the findings of a scoping review which set out to describe the provenance of the clinical pathway, whilst exploring the drivers for the development of AC in the UK.

2. Background

Since the early 1990s, the incidence of cancer has increased. In the UK there were over 375,000 new cancer cases every year in the period 2016–2018, with incidence rates having increased among those aged 0–24 by 19% and by 22% in those aged 25-49 in the last thirty years [1]. Growth in healthcare demand has driven innovations in care modelling and delivery with treatment, formerly requiring hospital admission, managed on a daycare or ambulatory basis. Consequently, many cancer patients now spend proportionally more time away from the inpatient setting; this is considered less disruptive to people’s lives. These ambulatory pathways also help meet an increasing demand for services, by freeing up hospital bed capacity [2, 3].

This evolution in cancer care delivery mirrors a shift in healthcare organisation and culture from one dominated by notions of biomedicine as “all-knowing” or omnipotent, to aspirations for a person-centred system within which patients and the public can exercise greater autonomy in relation to their health [4, 5]. More holistic models of healthcare can be traced back to the USA, where in the 1960s, it was referenced as person-centred care [6]. Following this, within nursing, innovations in US approaches to care, such as the notion of self-care as described by Orem [7], began to have an influence on how care was delivered in the UK, reframing patients as active partners. Simultaneously, over time, advances in technology, alongside shifts in law and human rights have all had bearing on the move to individualised, collaborative patient-centred care delivery [8]. Yet concepts such as involvement in care, self-care and self-management did not become embedded in the UK health policy until the turn of the millennium [6], and while more engaged, person-centred care is now a feature of healthcare commitment [9, 10], and there is a move towards more shared responsibility for health [11], opportunities to enact this in a transformative way within acute care specialties have been less developed than in community settings.

A London teaching hospital, University College London Hospitals NHS Foundation Trust (UCLH), was the first to pilot, then introduce AC in the UK in 2004, where it is now a mainstay of cancer treatment delivery. Ambulatory Care is understood to foster independence [12–14], creating opportunities to experience freedom from the hospital environment [15] and receive more personalised care [16]. However, AC comes with expectations, as patients need to self-administer timed medications, monitor for signs of infection, observe for treatment-related toxicities and undertake clinical measurements previously undertaken by nurses or other members of the healthcare team. Professionals working in the AC field often describe patients rising to this challenge and informally cite patients’ appreciation for the opportunity to receive their cancer treatment away from an inpatient ward. Little is empirically known, however, about patients’ experiences of this care pathway. A research study investigating different stakeholders’ experiences of a young people’s cancer AC service in England has recently been completed [17]. Reported here is a scoping review of the AC literature to provide the context of this care delivery model.

3. Methods

Within a health topic known to have a disparate evidence base, and in mapping the emergence of AC as a unique kind of healthcare culture, casting the net wide through a scoping review intended to capture both the complexity and genesis of this service model. This scoping review involved the exploratory and iterative mapping of the literature, the inclusion of unpublished literature and a consultation phase [18–20]. We worked with the Joanna Briggs Institute (JBI) guidance [21], which is underpinned by previous Levac et al. [19] and Arskey and O’Malley [18] scoping review frameworks. One of the primary objectives of this review was to answer the question: What were the drivers that informed the development of ambulatory care in the UK?

3.1. Inclusion and Exclusion

The review began with the development of a working protocol template with inclusion and exclusion criteria (Table 1) that related directly to the objective of this review. The population, concept, and context [21] were defined; thereafter the search strategy was developed and checked with a specialist librarian. To comprehensively explore the scope of the AC field, all types of published and grey forms of literature were eligible for inclusion from database inception up to 22 April 2022, published in English or in a Latin script. Adult, child, teenage and young adult ambulatory cancer services were included.

3.2. Consultation Exercise

An optional, yet respected component of the scoping methodology is the consultation exercise [19, 20]. This stakeholder engagement was undertaken in parallel to the synthesis of the literature, and comprised a conversation with six healthcare professionals considered critical to the development or delivery of AC. It followed a topic guide and involved sharing findings from the literature with the objective of bringing insight and additional perspectives [19]. The consultation helped inform the ensuing review and analysis by offering conceptual clarity and/or indications of complexity within a topic area with a limited evidence base; it furthermore yielded the identification of new citations. NHS Ethics and Health Research Authority (HRA) review was not required for this consultation process. Guidance on the number of individuals to engage in consultation does not feature in the scoping review methodology. Steps were taken to ensure that the six professionals understood how their contribution would be presented, however, and all willingly engaged in the exercise. With the exception of one individual, whose identity is critical to the reading of this text, those who contributed are referred to by role only.

3.3. Analysis

A hermeneutic approach to the interpretation of the literature was undertaken within scoping review process which, rather than seeing it as linear and finite, integrated the analysis, interpretation, and the search for new literature at different time points within the interwoven circles of inquiry: a search and acquisition circle and a wider analysis and interpretation circle that built on one another [22]. It extended the categorisation, comparing, contrasting and synthesis inherent in scoping review methodology [23] to a more critical engagement, that connected the reader with the text and the relationship of each individual reference to the emerging whole body of the AC literature. This was further appraised with narrative from the consultation exercise.

This iterative, hermeneutic approach to interpretation and development of understanding acknowledges that further reading of a body of literature may continue to contribute understanding of a subject; it is an effectively an ongoing process [22]. It ended therefore with the lead reviewer’s judgement that, for the purposes of the review, the material had been exhausted.

4. Literature Sources and Search Strategy

4.1. Literature Sources

Nine academic databases were selected across the fields of medicine, social science, nursing, psychology and healthcare (Medline, CINAHL Plus, SCOPUS, Embase, Web of Science, British Nursing Index (BNI), PsychINFO, Applied Social Sciences Index and Abstracts (ASSIA), and International Bibliography of the Social Sciences (IBSS)), using their entire cataloguing date fields. A manual search was conducted across the National Institute for Health and Care Excellence (NICE), the International Prospective Register of Systematic Reviews (PROSPERO), the University of York Social Policy Research Unit, Cochrane, and Google websites. A hand search was undertaken for policy, guidelines and meeting minutes at the one NHS hospital that had established a comprehensive AC service for evidence or information related to Ambulatory Care.

4.2. Search Strategy

Table 2 shows the main subject headings and search terms used across each database search. Supplementary Material File 1 lists the full search strategy for each of the nine databases. The same keywords and search terms were used to search the databases and relevant grey literature. The initial search strategy was built in OVID Medline and then employed across each database, with modifications according to each database’s configuration requirements. The strategy took account of the different synonyms for Ambulatory Care, including both North American and English spellings.

An initial search was undertaken in September 2019. No limits on date, language, or publication type were placed on each database search strategy. A total of 2,853 citations were exported to Endnote X9 and later to EndNote 20 (Clarivate Analytics) for screening. The reference lists of included studies were reviewed to identify additional papers that could be relevant. Citations within articles were also searched and captured for review using the snowball technique [24], as well as the key author searching.

The search strategy was rerun within each of the nine databases on 29 June 2020, generating 132 new citations for screening. Six new unique (non-duplicate) citations were imported to Endnote X9 (Clarivate Analytics) for full-text review. Database auto-alerts were used to check for new publications and on 22 April 2022 the search was run again, generating 157 new records which resulted in the inclusion of two papers that had been identified through citation searching.

Additional records were identified through hospital sources (n = 3), citation searching (n = 6) and the consultation exercise (n = 6) which had been undertaken before the second search in June 2020. Duplicates were removed in all three searches (n = 917 in 2019, n = 14 in 2020 and n = 11 in 2022) and through further manual removal where required during title screening (n = 12). After duplicate records were removed in all searches, the total number of records that remained for screening by title was 2203.

4.3. Study Selection

The search and selection process undertaken by the lead author (AF) is detailed in the PRISMA flow chart (Figure 1) which combines the results of all three searches. Citations were exported to Endnote X9 (subsequently to Endnote 20), where title and abstract relevance screening was undertaken, working with the inclusion and exclusion criteria (Table 1). Given that the nomenclature “ambulatory care” can also refer to the standard daycare services, the review worked with the lead author’s clinical knowledge to screen and filter relevant publications. In becoming more familiar with the literature, “post hoc” exclusion criteria were added [19], so that reference selection became more relevant and refined.

As well as the key author searches, citations within the records were also searched and captured for appraisal. Records identified for full-text review were shared with an independent reviewer (RMT) who, while working with the agreed inclusion and exclusion criteria, completed a test of relevance amongst all records selected for inclusion and exclusion. Where there was no consensus, these records were shared with a named clinician in the field for their independent review.

5. Results

A total of 3,142 citations were identified through database searching, with 15 records identified through additional sources. After duplicates had been removed, there were a total of 2,203 records. The number of full-text records assessed for eligibility totalled 105, from which 48 records were subsequently excluded. The scoping review of the AC literature thus comprised a total of 57 records as shown in Figure 1.

5.1. Study Characteristics

The AC literature included in the scoping review (n = 57) covers the chronological period 1979–2022. Of this, the distribution of published literature (n = 51) by date and geographical source origin is shown in Figures 2 and 3, respectively. Dominant countries of source origin are the USA (28 records) and the UK (17 records). A full breakdown of the geographical origin by individual publication is shown in Tables 3 and 4. Before 2005, the USA was the predominant country of source origin. Among the 38 academic journal publications included, just three reported primary research outcomes with the majority providing descriptive accounts of AC services.

Six papers were categorised as primary research, comprising three academic publications [26, 28, 29] and three research dissertations [12, 25, 27]. The characteristics and study methods are shown in Table 3 and comprise qualitative interview (n = 4), questionnaire (n = 1) and instrument measurement (n = 1). Among the research, Tighe and colleagues [29] and Morrison [27] focused on nursing practice in Ambulatory Care. Among the other three research studies, Grimm and colleagues [28] explored the role and needs of caregivers, whereas Nissim and colleagues [26], Mcmonagle [25], and Statham [12] explored the experiences of AC patients. In addition, there were two quality improvement projects [40, 41], a service evaluation [42] and a form of literature review [43].

Twelve publications were categorised as retrospective data studies that reported analyses of existing health service data; characteristics of which are detailed among the data papers in Table 3. Articles published between 2008 and 2021 with one outlier from 1982, they predominately focus on demonstrating the feasibility, safety, clinical outcomes and efficiencies associated with the AC pathway within differing international settings [2, 3, 30–35, 37–39]. Patient-reported outcomes were not included as a part of these analyses.

Nine conference abstracts met the inclusion criteria, published between 2012 and 2019 [62–70]. Four abstracts centred on adult patient populations [62, 63, 68, 70] and four service design and delivery [63, 66, 67, 69]. In two abstracts, Breen and colleagues [64] and Overbeek and Vos and Koene [70] explored caregiver education which they concluded was critical to safety in the ambulatory cancer setting. Several abstracts described the role of experienced cancer nurses in helping to establish and innovate within the AC field [63–67, 70]. Conference abstracts did not report primary research activity.

The remaining literature comprised discussion papers (n = 21) which focused on the AC context, setting up of AC services or professional accounts of the benefits or challenges of the care model (Table 4). In addition, the remaining literature included a book chapter [71], published guidelines [72] and local hospital documents (n = 3) which comprised an operational policy [73], patient questionnaire responses [74] and an AC case study report [13].

6. Discussion

The narrative synthesis of the literature integrated with the consultation findings, enabled the identification of four themes that reflected the drivers for the development of AC: financial drivers; optimisation of bed capacity; advances in technology and supportive care; and professional motivation to improve cancer experience. The resulting synthesis of the literature presents a critical descriptive analysis.

6.1. Drivers That Informed Ambulatory Care Service Development in the UK

The main driver for the development of AC in the UK was usually understood to be the ability to increase cancer treatment capacity [3, 42]. A body of work confirms the safety of the pathway [3, 33, 37, 38, 40, 53] but there was less literature about the context and individual storyline of AC’s development, something that this review aimed to address. When interpreting the chronology of the review findings context became important; many treatments that used to require prolonged hospitalisation are now routinely given on a daycare basis. This literature, whilst helping inform understanding about the drivers for AC, is not necessarily reflective of contemporary AC practice. Shifts in societal thinking on more actively engaging with health- and self-care have also evolved considerably over the last three decades – the period that this review covers.

6.1.1. Financial Drivers

Practitioners working in the UK’s first AC service often described a site visit to Memorial Sloan Kettering Cancer Center (MSKCC), New York, in the early 2000s as the precursor to piloting ambulatory cancer care in the UK [56]. Ambulatory Care as a concept was conceived in the USA where by 1995, considerable progress had been made to shift inpatient cancer treatment to outpatient or ambulatory pathways [39, 57, 58, 61]. According to Schulmeister [58], AC evolved into something of a misnomer, as non-ambulant patients also accessed these services.

“A very expensive venture” [49], cancer treatment comes at a cost in the USA, borne either personally, by one’s insurance provider or by government-funded programmes such as Medicaid or Medicare to help people on low or no income. Within this context, efficiencies in care can be seen as one of the key drivers influencing the development of AC in the USA. These efficiencies have centred on treatment cost reduction [2, 31, 49, 60, 62, 65] or cost containment [58].

Ambulatory Care is cheaper than an overnight hospital stay in the NHS, primarily due to reduced staffing and inpatient overheads [3]. In a literature review of outpatient autologous haematopoietic stem cell transplant (AHSCT), Richie [43] noted how the cost of AHSCT drove the ambulatory model in the USA and Canada. In efforts to demonstrate the safety and feasibility of AC in Argentina, among what the authors described as a poorly resourced population, Villegas and colleagues [33] cited reduced cost as the driver for, and the associated benefit of the pathway. It is not clear, however, from the literature who the intended beneficiary is within this drive for reduced healthcare costs: the provider, the patient or the system.

6.1.2. Optimisation of Bed Capacity

Rather than cost saving the UK literature describes a lack of inpatient beds to ensure delivery of timely cancer treatment as the main contributing factor to AC’s development [3, 43, 47, 56, 63]. Sive and colleagues described the opportunity to increase the treatment capacity as the impetus for establishing AC within the UK in 2004 [3]. Here, an additional 1443 adult cancer treatment episodes were successfully delivered via AC across the 6-year period (2005–2011), avoiding treatment delays, maximising treatment outcomes and freeing up hospital beds for acutely unwell patients [3]. Within other international literature, transitioning chemotherapy regimens that were traditionally given as an inpatient to an outpatient basis to manage increasing demand on inpatient beds was also described by Li and colleagues [30] as a key driver. Within non USA literature, avoiding delays in treatment due to limited bed capacity was described by Bakhshi, Singh, and Swaroop [2] as one of the drivers for piloting the ambulatory model to give consolidation chemotherapy to paediatric haematology patients in India.

6.1.3. Advances in Technology and Supportive Care

The first published examples of AC originated in the US four decades ago and involved the administration of high-dose methotrexate (HDMTX) [39, 60, 61]. Other clinicians followed, demonstrating the safe ambulation of HDMTX, typically used to treat osteosarcoma or acute leukaemia [33, 37, 38, 40, 53]. Confidence in the safety and efficacy of the pathway has extended the AC treatment portfolio in some larger cancer centres to include other high-dose chemotherapy treatments [2, 3, 14, 15, 26, 30–32, 41, 43, 56, 59, 71]. Autologous haematopoietic transplant [3, 14, 28, 34, 51, 54], allogenic haematopoietic transplant [3, 14, 28, 36, 54] and more recently, new modalities of care including Chimeric Antigen Receptor T-cell (CAR-T) therapy [16, 44–46] are also being managed on an ambulatory basis.

Alongside the drive to bring about healthcare efficiencies in response to inpatient bed availability or increased inpatient costs [49], advances in technology and supportive care medications have also influenced the transition of historically inpatient chemotherapy treatment into the ambulatory setting. The creation of portable infusion pumps in the 1960s paved the way for safer treatment delivery. Becoming more commercially available in subsequent decades, they enable infusion of chemotherapy, supportive medication and/or hydrating fluids on an ambulatory basis [50, 71]. Eleven publications cited portable infusion devices, programmable to give continuous as well as intermittent infusions, as a key influencer in the drive to pilot AC [14, 15, 32, 49–51, 53, 56–58, 71]. Transitioning chemotherapy to an AC regimen usually requires protocol adjustment to ensure drug stability [47] and sequencing so that the treatment can run safely with the minimal intervention [15], enabling patients to take care of the infusion progress and monitoring requirements themselves.

Whilst the potential use of portable infusion technology in the ambulatory setting has been an option since the late 1970s [61], treatment-related toxicities (such as those seen with HDMTX, ifosfamide, cisplatin or cytarabine) in conjunction with chemotherapy-induced nausea, vomiting and myelosuppression of the immune system, meant that inpatient treatment remained the mainstay. It was the development of haematopoietic growth factors that reduced the severity and length of myelosuppression, alongside better antiemetics and other supportive care medications, which instigated more widespread piloting and development of AC [36, 49, 54, 57].

6.1.4. Professional Motivation to Improve Patient Experience

Biomedicine is often presented as the driving force behind improvements in cancer care, but alongside this is the reconceptualisation of living with and beyond cancer [75], with patients increasingly regarded as active partners in their care [9, 11]. Undertaking elements of self-care is fundamental to AC. The independence [59], control [51, 52, 59, 66] and promotion of normalcy [15, 42, 51, 52, 56, 61] understood to be derived through one’s willingness to undertake self-care responsibilities, were reoccurring themes in the review findings that aligned with perceptions of enhanced patient experience. There was additionally a professional perception that not all patients require continuous nursing care during cancer treatment [14, 56, 63].

Across the USA, ambulatory care refers to all outpatient treatment, irrespective of illness or disease group. Since its inception in the 1990s in the USA, the professional specialty of ambulatory care nursing has emphasised both patient individuality and the central role of nursing [55]. The setup of AC requires medical, and not least pharmacy expertise, and once established, AC requires multidisciplinary coordination and management. The literature, however, suggests that in the UK the operational running of AC is, for the most part, a nurse-led service.

Concern for patient experience often sits within the nursing domain: among the 21 publications that promoted the potential of AC to enhance patient experience as a driver for the development and adoption of the service, nine nurse authors led 16 publications. Nirenberg is a central nursing figure in the “storyline” of AC. In their 1979 paper titled “The Day Hospital: ambulatory care” she and a clinical colleague described the set-up of an adolescent unit at MSKCC, driven by motivation to promote a degree of normality in young people’s education and social life during treatment for cancer [61]. Established during a consultation with her (and with an agreement to waive anonymity) is that their early, revolutionary approach went on to inform the establishment of the children’s AC service at MSKCC, dispelling worries a patient’s family might have about safety in the ambulatory setting. The idea that people should not be defined by their cancer was central to these services, as well as the critical role played by the family in supporting the delivery of care. Noteworthy is the fact that the specialty of adolescent cancer care had not been established until c1990 in the UK [76, 77].

Across the AC literature, there were indications that AC positively contributed to patient experience [12, 15, 16, 25, 26, 28, 41, 42, 47, 48, 51, 52, 56, 61, 67]. Quality of life [2, 53], preference [57] and satisfaction with care were also reported [25, 41, 49]. Though concern for patient experience is evident within the literature, it was rarely positioned as the principal driver for the development of an AC service. The scoping review suggests that within a field where there has been limited research, the relationship between system drivers for AC, responsibility for care and the pathway’s ability to contribute to positive experience remains obscure.

6.2. The Consultation Exercise: Integrating Context to the Review Findings

Concurrent with synthesis of the literature, author AF consulted with the six professionals about their involvement in developing AC. During this exercise, she described some of the literature, to help build a more composite and contextualised understanding of the findings. For example, during the consultation, a specialist pharmacist contributed their first-hand experience of listening to the AC team from MSKCC present at a conference in c2002. Hearing about how MSKCC had successfully transitioned HDMX to an ambulatory pathway, had compelled the pharmacist to propose the idea to pilot a similar model in a UK hospital, UCLH. They recalled the realisation that with protocol adjustments, education, and the use of technology, the osteosarcoma population who were young, and often only in the hospital for intravenous hyperhydration, fluid monitoring and administration of folinic acid, did not need to be confined to a hospital ward. A visit to MSKCC followed and oncology patients diagnosed with osteosarcoma became some of the first adult AC patients in the UK to ambulate with HDMX, which helped demonstrate safety and confidence in the service [13]. A matron consulted described how, as confidence in the pathway grew, there were recurrent conversations between doctors, pharmacists, and nurses to identify other chemotherapy protocols that could be transitioned to an ambulatory basis.

The consultation also helped explicate some of the literature findings, for example, the imperative to innovate and manage inpatient bed capacity. The NHS Cancer Plan [78] directed the centralisation of specialist services in a drive to improve cancer outcomes in England. A consultant haematologist described that whilst centralisation of cancer treatment “pooled’ expertise and strengthened outcomes, it both increased the size of cancer services and entailed patients having to travel long distances for treatment. There became, they explained, an imperative to invest in AC. They contextualised this by describing that if many of the complex cancer treatments required inpatient admission, these would not only place pressure on beds and timely treatment, but they would also require separation of a patient from their family. Besides being more cost-efficient, the haematologist understood that this was why large cancer hospitals in the USA had a commercial hotel on campus, where an accompanying companion could help share care.

Consistent with the literature, the haematologist spoke about the need to optimise bed capacity as the primary driver for the development of AC in the UK. Within haematology, inpatient services consistently run at 95% occupancy, explained a senior nurse we consulted, indicating that this fact alone drove the requirement to transition some treatment to an ambulatory setting. They explained how many complex treatments had a step-down component with less care or supervision requirements than at other points, and during month-long admissions, there were periods where patients were not particularly unwell but were considered at risk. Through consultation, we learned how some of the first haematology AC treatments were determined based on “well but at risk,” a concept evident within the hospital’s adult AC policy [73]. Identified through the consultation too, was the opportunity for AC to benefit clinical research and trial activity through having a larger patient cohort.

Another driver reported in the consultation exercise, also consistent with the literature, was patient experience. This, according to a consultant oncologist was central to the development of teenage and young adult AC. The fact that a patient is in control of their own time management and lifestyle was considered advantageous for all ages and particularly for younger people. The knowledge gap here, posited by some of the professionals consulted, was how the healthcare system delivers cancer care safely, in a different way, while ensuring the best possible patient outcomes and experience.

6.3. Strengths and Limitations of This Scoping Review

This is the first review of the development of AC in the UK. The scoping review brings together literature that contributes knowledge and evidence about AC’s development as a pathway and clinical service. Not placing restrictions on publication date has facilitated a more extensive, and chronological presentation of the AC literature than previously described.

The JBI Manual for Evidence Synthesis recommends that the record selection should be undertaken by at least two independent reviewers from the point of title/abstract screening [79]. In this review, the process of record selection involved the secondary review of all full-text publications that met the prespecified criteria for inclusion as it was not feasible to undertake this earlier in the process. This could be considered a limitation of our review. The consultation exercise drew on the experiences of six professionals identified as critical to the development of AC. All except one individual had contributed to the development of AC services at UCLH. While this aligned with our primary intent to build understanding about the development of UK AC services, there is recognition that including consultation with others, as they became known through engagement with the literature, may have yielded further insights.

Critical to the transition of inpatient cancer pathways to an ambulatory model of care is the pharmacist role. There is expansive literature within the field of pharmacy and pharmacology that describes the adjustment to chemotherapy formulations and modes of delivery required for AC. Whilst these publications were not in scope for this review, this body of work should be recognised as part of the safety net and backbone of the development of AC services.

7. Conclusion

This scoping review set out to describe the development of ambulatory cancer care in the UK from its international commissioning and philosophical foundations. Presented here is an integrated and historical account of the development of UK ambulatory cancer care in the NHS, which offers the first account of its provenance.

Whilst AC is still regarded as somewhat novel in the UK, by the 1990s in the USA, the pathway was well established. The review has evidenced the impetus for AC as the ability to safely manage increased service demand, whilst ensuring timely access to cancer treatment and efficient management of costs. Advances in infusion therapy devices and haematopoietic growth factors, alongside better antiemetics and other supportive care medications have culminated in AC becoming increasingly feasible. The perceived benefit to patient experience was also evidenced in the literature as a basis from which to develop the commissioning of AC. What is feasible may not be practical in all NHS settings, however, nor does this consider the views of all stakeholders, including patients.

The review process has been able to clearly explain the claims and concepts attributed to the AC model as a basis for further exploration through empirical study. Accounting for different perspectives, including service user experience, will be important to inform further development of the service in the UK or when expanding the AC model to different international cancer care settings.

Data Availability

The details of the complete search strategies used to support the findings of this scoping review are included within the supplementary information file.

Disclosure

The views expressed are those of the authors and not necessarily those of the National Institute for Health and Care Research (NIHR) UK, Health Education England, the NHS or the UK Department of Health and Social Care.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Acknowledgments

The authors would like to acknowledge co-researchers Sadhia, Ali, Emma Haslam and Kristy Wang, who read, considered and commented on the literature review findings, drawing on their own experience of NHS cancer services. The authors would also like to acknowledge the six professionals who took part in the consultation exercise. The lead author, Alison Finch, a former NIHR Clinical Doctoral Research Fellow (NIHR ICA-CDRF-2018-04-ST2-034) was funded by Health Education England (HEE)/National Institute for Health and Care Research (NIHR) to undertake the research associated with this review. Silvie Cooper and Rosalind Raine are funded by the NIHR Applied Research Collaboration North Thames. Rachel Taylor is part funded by the UCLH Charity, and Faith Gibson is supported in part by the NIHR Great Ormond Street Hospital Biomedical Research Centre.

Supplementary Materials

The supplementary information file contains the complete search strategies used for this review. (Supplementary Materials)

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Copyright © 2023 Alison Finch et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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