Background

There are more people living with cancer than ever before and the East Midlands Cancer Alliance (EMCA) is committed to ensuring that each and every one of them are supported through access to personalised care and support from diagnosis onwards. Personalising care and empowering people to better self-manage has the potential to reduce delays in diagnosing recurrence, provide for better management of consequences of disease and/or treatment, improve patient satisfaction and encourage people to integrate with existing health and wellbeing programmes to live well and keep healthy.

The NHS Long Term Plan published in January 2019 states that:

By 2021, where appropriate every person diagnosed with cancer will have access to personalised care, including needs assessment, a care plan and health and wellbeing information and support. This will be delivered in line with the NHS Comprehensive Model of Personalised Care as mentioned in the Long Term Plan published in January 2019. This will empower people to manage their care and the impact of their cancer, and maximise the potential of digital and community-based support. Over the next three years every patient with cancer will get the personalised care package. All patients, including those with secondary cancers, will have access to the right expertise and support, including a Clinical Nurse Specialist or other support worker.

After treatment, patients will move to a follow-up pathway that suits their needs, and ensures they can get rapid access to clinical support where they are worried that their cancer may have recurred.  This stratified follow-up approach will be established in all Trusts for breast cancer in 2019, for prostate and colorectal cancers in 2020 and for other cancers where clinically appropriate by 2023.

Personalised Follow Up

In line with national guidance, the EMCA is developing guidelines for all Trusts across the region.  The guidance supports the redesign of follow-up pathways. This will ensure a better use of resources across the whole system, from secondary to primary care resulting in a high quality, individualised care package that supports people living with cancer.

The EMCA has published Personalised Stratified Follow-Up Guidelines people with a breast cancer diagnosis and for people with a prostate cancer diagnosis.

There is an expectation that more than two-thirds of all people with breast cancer diagnosis and half of men with a prostate cancer diagnosis could be followed-up on a supported self-management pathway.

This means fewer follow-up appointments for many but will incorporate key interventions that ensure ongoing assessment means the right support is identified at the right time for people affected by cancer.

These interventions form ‘The Personalised Care Package’ (previously the Recovery Package) and incorporates a Personalised Care and Support Plan, informed by an Holistic Needs Assessment. In addition, a Treatment Summary, Health & Wellbeing Support and Information and a Cancer Care Review will be provided.

pdfEMCA Personalised Follow-Up Guidelines Breast

pdfEMCA Personalised Stratified Follow Up Guidelines Colorectal

pdfEMCA Personalised Stratified Follow Up Guidelines Endometrial

pdfEMCA Personalised Stratified Follow up Guidelines Generic

pdfEMCA Personalised Stratified Follow Up Guidelines Lymphoma

pdfEMCA Personalised Follow-Up Guidelines Prostate

pdfEMCA Personalised Stratified Follow Up Guidelines Thyroid

 

pdfEMCA Key Worker Policy

Living With and Beyond Cancer videos (courtesy of Northampton General Hospital

Holistic Needs Assessment

A checklist of concerns that cover physical, emotional, practical, spiritual and financial issues ensuring each area is addressed and a Care Plan is created for those identified as needing specific support. The care plan offers suggestions to manage the concerns including signposting to other services or information services that can help. An HNA can be offered at key points during the pathway to meet the needs of the individual. This can be done ideally electronically or on paper

Treatment Summary (TS)

A TS is a document produced by the Doctor or Specialist Nurse at the end of active treatment for cancer. The TS details the diagnosis, stage and any relevant pathology information. It also includes any surgery, chemotherapy, radiotherapy or any other therapies that the person may have received during the treatment phase. It is followed by specific information on signs and symptoms of recurrence as well as significant consequences of disease and/or treatment. This is important as this information may be needed at a later date by long term survivors of cancer who may develop issues. A TS and an HNA inform the Cancer Care Review.

Cancer Care Review (CCR)

The CCR is a holistic conversation that is carried out after the end of treatment by the GP or Practice Nurse in Primary Care and is based on the TS and HNA. This discussion ensures the person can discuss their cancer experience and continues to support self- management. It reinforces the messages given via the TS and allows an opportunity to raise any concerns that may be affecting the quality of life of the person living with and beyond cancer. 

Health & Wellbeing Intervention (HWBI)

HWBI are any support, education events or programmes that enable the patient to transition from treatment for cancer to supported self-management. The support can range from one-to-one information sessions to group sessions on a variety of topics designed to help with the emotional and practical aspects of life with and beyond cancer.

Follow-Up Models for Colorectal and Prostate Cancers are under development and will be in place by March 2021.