Summary of the impact

Fallowfield designed, ran and demonstrated the long-term effectiveness of a comprehensive three-day training programme that significantly improved cancer doctors' communication skills. Publications from a major randomised trial showed that improvements transferred into the clinical setting and were enduring. These findings were pivotal and led to key components of courses being embedded in a Department of Health initiative called Connected; this trained facilitators, and provided materials for training all health-care professionals (HCPs). Attendance at Connected courses became mandatory for all consultant staff. Over 16,000 UK HCPs have participated since 2008.

Underpinning research

Communication is a core clinical skill. Poor or insufficient training of HCPs in communication skills has several negative effects for staff and patients alike [see Section 3, R1]. These include stress, lack of job satisfaction and burn-out in health-care professionals. Poor communication may also lead to increased levels of patient dissatisfaction and anxiety, confusion about the significance of a diagnosis and its prognosis, questionable consent to diagnostic and therapeutic procedures and decreased treatment adherence. Recognition of these issues underpinned a commitment in the NHS Cancer Plan to make advanced communication skills a part of continuing professional development.

Some used to doubt that communications skills could be taught and assumed that HCPs were intrinsically either good or bad communicators. Most medical training also relied heavily on an apprenticeship model of learning — namely, watching senior colleagues and mimicking their variable behaviours with patients. However, pioneers in adult-learning theory such as Rogers, Knowles and Friere demonstrated that more appropriate educational interventions could enhance any individual's skills, and Lipkin showed that this could be applied to general communication in medicine. In the 1990s, Fallowfield developed an innovative communication-skills training programme aimed specifically at doctors and nurses working in cancer medicine. This training model is learner-centred and integrates exercises and activities designed to create simultaneous, in contrast to sequential, skills development, knowledge acquisition and personal awareness of how these factors impact upon both clinician and patient.

Following Fallowfield's arrival at Sussex in 2001, she completed the analysis of, and then published, a major randomised controlled trial (RCT) conducted in 34 UK cancer centres with 160 oncologists and >3,000 cancer patients [R2]. This RCT evaluated the effectiveness of her three- day training programme and provided clear evidence that it resulted in positive behavioural changes amongst oncologists three months after training. Most notably, oncologists used fewer leading questions, had higher rates of use of focused and open questions, showed increased levels of empathy and responded more appropriately to patients' cues. The behavioural data were obtained from video-recordings of consultations with real patients and were reliably coded by independent observers.

Subsequent analyses and publications showed that most of these benefits were still observable at 12-month follow-up (i.e. 15 months post-training) and that, as these earlier skills became embedded into the doctors' repertoires, further skills emerged — such as an increased ability to summarise information, and not interrupting patients [R3]. No previous research had ever demonstrated transfer into a clinical setting or the long-term efficacy of training. Most work relied on pre- and immediate post-course changes, self-evaluated and/or using patient simulators rather than real patients. The measured improvements in communication skills shown following participation in Fallowfield's courses were mirrored by more favourable self-reported beliefs and psychosocial attitudes among physicians [R4]. For example, trained physicians were more likely to agree that considering patients' psychosocial concerns alongside their organic problems was important. Two systematic reviews have concluded that Fallowfield's research is one of only three adequate evaluations of communication-skills training courses out of >50 published studies [R5, R6].

References to the research

Other references

Outputs can be provided by the University on request.

Details of the impact

The NHS Cancer Plan [see Section 5, C1] noted that

...some patients say they receive excellent care, with sensitive and thoughtful communication, clear information about their disease and its treatment, and good support when it is needed. Others report being given bad news in a deeply insensitive way, being left in the dark about their condition and badly informed about their treatment and care.

The Plan proposed that all hospital consultants working in cancer would have to demonstrate competence in communication with patients and that advanced communication-skills training would form part of their continuing professional development. This was subsequently reinforced by NICE guidelines which proposed that accredited training courses should be made available for all health professionals working with cancer patients [C2].

On the strength of the RCT validating Fallowfield's training course [see Section 3, R2, R3], many of the teaching components designed by Fallowfield became incorporated into Connected [C3], a national communication-skills training course for cancer clinicians that was launched in 2008. The scheme uses a cascade model in which communication-skills facilitators are initially trained at Cancer Network level to deliver the Connected workshops to HCPs [C4]. Completion of this training package and the associated workshops has been mandatory for all clinicians working with cancer patients from 2008-2013. Over that period more than 16,600 health professionals from 48 Cancer Networks in the UK have participated [C5]. Essential elements of the three-day workshops are that they are learner-centred and involve role-play with trained actors (patient simulators) taking the role of patients and carers. Participants are also provided with feedback on their performance. Course evaluation data indicated that 95 per cent of attendees said the course met their training needs and 84 per cent said they would definitely recommend the course to a colleague [C5]. Fallowfield is acknowledged as one of the authors of the Participant Handbook that accompanies the workshops, and her work is extensively referenced in the Appendices on supporting evidence and further reading [C4].

As a result of the international recognition of Fallowfield's work, similar training programmes are being implemented in Europe and elsewhere. For example, in Switzerland, communication-skills training for medical oncologists was made compulsory in 2006, in large part because of the findings described in R2 above [C7]. In Australia, a large programme of communication-skills training has been implemented, involving many hundreds of health-care professionals. Fallowfield was directly involved in initial training, again as a result of her international research profile in the area and her publications [R1, R2, R3, R4), demonstrating the benefit of such programmes to both patients and health-care professionals [C8].

Sources to corroborate the impact

C1 Department of Health (2000) The NHS Cancer plan. London: DoH.

C2 National Institute for Clinical Excellence (2004) Improving Supportive and Palliative Care for Adults with Cancer. London: NICE.

C3 Connected website link at: https://www.connectedonlinebookings.co.uk. The `Evidence' tab acknowledges the input of Fallowfield in the design and implementation of the package and also cites the references in Section 3 as part of the supporting evidence base.

C4 Connected Handbook: Advanced Communication Skills. Participant Handbook published by National Cancer Action Team.

C5 Connected Final Report published by National Cancer Action Team.

C6 Testimonial from Consultant Medical Oncologist and Lead Cancer Clinician at the Whittington NHS Trust. She was national clinical lead on the Expert Advisory Group overseeing Connected, has run many training workshops herself after being trained as a communication-skills facilitator by Fallowfield, and has written a short testimonial about Lesley Fallowfield's contribution to Connected. It includes the following comment:

Lesley's work was integral to the development of Connected© and many of her original course materials were donated to the Connected© programme.

C7 Testimonial from Professor at Universitätsspital Basel who is a senior medical oncologist, involved in the implementation of communication-skills training in Switzerland since the 1990s. He is senior author on position papers on this topic published in Annals of Oncology in 1999 and 2009. His testimonial includes the following comment:

The publication of the Lancet paper in 2002 (Fallowfield, L., Jenkins, V., Farewell, V., Saul, J., Duffy, A. and Eves, R. (2002) `Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial', The Lancet, 359(9307): 650-656) was extremely helpful in making CST mandatory for every medical oncologist in Switzerland since 2006.

C8 Testimonial from Senior Principal Research Fellow of NHMRC and Co-Director of the Centre for Medical Psychology and Evidence-Based Decision-Making. University of Sydney.