Breast cancer survivors control their follow-up care in Maidstone

Case study summary

Supported by Kent and Medway Cancer Alliance, the Open Access Programme at Maidstone hospital puts patients in control of their breast cancer recovery. Based upon a similar model at the Royal Marsden Hospital, patients have access to telephone support, advice and appropriate clinical follow-up, in addition to regular mammograms, for a period of five years following treatment for breast cancer.

The idea

Supported by Kent and Medway Cancer Alliance, the breast cancer team at Maidstone hospital sought to give patients access to support, advice and appropriate clinical follow-up. This includes regular mammograms, for a period of five years, following treatment for breast cancer. Recognising that patients are very individual and the way in which they want to be supported may change during their recovery, the team introduced an Open Access Programme, based upon a successful model in place at the Royal Marsden Hospital.

The service model

The multi-disciplinary team (MDT) identify suitable patients who could benefit from the Open Access Programme. In addition to their knowledge of their patient, the team reviews the stratified follow-up criteria and previously completed Holistic Needs Assessment (HNA). Although the majority of patients could potentially benefit from the Programme, it is generally not offered to patients recovering from inflammatory breast cancer, those with complex comorbidities or patients unable to effectively complete breast self-examinations. Post-surgery patients will attend an additional surgical outpatient appointment before joining the Programme.

Patients joining the Programme are encouraged to contact their Cancer Nurse with any concerns, worries or information needs, at any time during their recovery. They understand that they are in charge of their recovery and can arrange follow-up clinical appointments as required. They also receive an information pack that includes a breast examination chart, treatment summary and information about mammograms, medications, potential treatment side-effects and wellbeing.

The breast cancer nurse handles all phone calls from patients on the Programme. This might involve giving the patient advice, information or reassurance, or sign-posting them to another service. It might also result in the patient being invited to a clinical appointment with their oncologist or surgeon.

A questionnaire is used to screen the patient’s ongoing health and wellbeing concerns. Issued to coincide with their mammograms, patients are contacted by an appropriate member of the multi-disciplinary team depending on the outcome of their mammogram and reporting of any concerns. A patient with an ‘abnormal’ mammogram is contacted by telephone so that their results can be explained and a clinical appointment arranged. A patient with a ‘normal’ mammogram who has reported any concerns in their questionnaire, will be followed up by phone and invited to a clinic. A patient with a ‘normal’ mammogram reporting no concerns, will be booked in for their next mammogram and provided with a letter to re-emphasise when and how to contact their nurse.

Early results

The impact of the Open Access Programme has not yet been formally assessed. Initial findings suggest:

  • A reduction of 3,000 breast outpatient appointments
  • Patients access suitable clinical appointments and contact their nurse appropriately.

Patient benefits

  • Timely referral to an appropriate clinician (ie surgeon, oncologist, nurse)
  • Appointments aligned to patient need or want
  • Fast access to the Cancer Nurse to answer questions and concerns.


  • The team is trialling the use of a database to manage Programme patients and their call/recall for mammograms and appointments
  • Patient feedback is being used to strengthen the patient needs questionnaire.
  • Transformational Funding will support all providers within Kent and Medway Cancer Alliance to use a networked system to support self-management pathways for breast cancer patients.
  • The funding will further development of the current Kent & Medway wide cancer information system Infoflex which links our 4 Trust cancer information systems and could create a single cancer data repository, providing improved functionality, automatic population of templates; safe call and re-call processes and development of a patient app/portal to support self-care.


Putting patients in control of their follow-up has enabled the team to tailor support to the needs of the individual patient.

“ 3,000 women will now get results quicker, be able to self-report problems and be seen quicker, from previously waiting months to be seen in clinic, often by someone they don’t know.”

“Patients have many questions after treatment and often need reassurance. The Open Access Programme gives them easy access to their Cancer Nurse who they build a relationship with during treatment. They no longer have to wait for their next outpatient appointment to ask their Nurse a question or seek reassurance. Equally as important, they don’t have to wait for an appointment to discuss a clinical issue, they simply talk to their nurse who will book them into a clinical appointment with the most appropriate clinician.”

Mrs Claire Chalmers, Consultant Breast and Oncoplastic Surgeon, Maidstone Hospital.

Implementation tips

  • It needs resourcing including a nurse practitioner and a database coordinator
  • The HNA is completed outside of the Programme, but the MDT hope to embed electronic HNAs into the Programme and database