Clinical nurse specialists (CNS) in cancer perform a range of complex activities, including the management of care. However, they often report a high administrative burden for services, which makes providing expert nursing care challenging. Administrative work for a service can be seen as a priority for non-nurses, yet a high administrative burden allows less time for complex nursing care. A London trust admitted a mean of four lung cancer patients per month for symptom control in progressive disease or end-of-life care, with a mean stay of 6 days. This was often a default location: the acute hospital was not always the patient's preferred place of care for end of life. The CNS negotiated away the administrative burden, and adopted standard proactive case management in line with national standards, resulting in fewer admissions for non-acute problems. In conclusion, CNSs who practise proactive case management and refocus services in line with best practice represent a good return on investment.

Alison Leary - Professor of Healthcare and Workforce Modelling, London Southbank University

Jane Baxter - Clinical Nurse Specialist, Community Palliative Care, Meadow House Hospice, Middlesex