Paradoxical support: exploring use of the holistic needs assessment and its contribution to meaningful support for women with breast cancer

Breast cancer is a widespread disease, with rapidly increasing numbers of people living with or beyond this diagnosis (Breast Cancer Care, 2018a). The disease is associated with a complex array of physical, psychological and social impacts, which may continue long after treatment (National Cancer Institute, 2014). The concept of ‘personalised care’ (formerly the ‘recovery package’) was introduced in the UK as part of a nation-wide agenda to support women with breast cancer, of which holistic needs assessment (HNA) is a core element (National Health Service (NHS), 2019). These assessments give people opportunities to raise their concerns and have these addressed through a meaningful discussion and subsequent care plan (National Cancer Survivorship Initiative, 2013). Across the UK, implementation of the HNA varies significantly in its approach and delivery methods. Although various types of HNA tools exist, few studies have explored the perspective of either healthcare professionals or individuals with cancer around use of these tools. However, there is some indication that the HNA’s contribution to addressing concerns arising from cancer diagnoses is complex, and often minimal. The current study aimed to understand the contribution of the HNA in assessing and supporting the needs of women with breast cancer, and understanding the barriers and enablers to use of the assessment. The study adopted a multiple case-study approach, including two acute NHS Trusts and four hospital sites. In total, 24 women with breast cancer and 24 staff were recruited. Data collection involved face-to-face interviews with all participants, follow-up interviews with women and observations of HNA completion wherever possible. Furthermore, HNA care plans and other key documentation were analysed to compile a case around use of the HNA in each NHS Trust, with the primary focus being Macmillan Cancer Support’s electronic HNA (eHNA). A Framework Analysis approach was adopted to identify key categories and explanations within the data. Findings showed that the HNA’s contribution in supporting women’s needs was complex, and dependent on multifactorial influences. Framework analysis identified a trio of key factors which affected participants’ perceptions of the (e)HNA’s contribution, which were how women’s views and judgements influenced these perceptions, how the staff member’s views and judgements influenced these perceptions, and the influence of the broader context and culture within their organisations. An apparent superficial implementation of HNAs in these case studies seemed to facilitate cultures of achieving targets over the value of meaningful conversations. Therefore, rather than providing support to women, the HNA's contribution appeared paradoxical in many cases, through eliciting either indifferent or negative feelings among women. However, there were notable differences observed between case studies, with more negative views towards the assessment expressed by participants at Case Study 1 compared with Case Study 2. Women perceived the HNA as meaningful ‘in principle’, as this provided an opportunity to have their needs met, and the care plan offered a valuable safety net and physical reminder of the conversation. However, challenges and room for improvement were noted by both staff and women in HNA implementation processes. A series of recommendations for practice settings were developed to support the delivery of increasingly personalised HNAs, focusing around: introductions to the HNA, the practicalities of arranging the HNA and maximising the value of each element of the HNA process