Personalised care

More people than ever are living with and surviving cancer.

Personalised cancer care means providing patients with access to care and support that meets their individual needs – from the moment they receive their cancer diagnosis – so that they can live as full, healthy and active a life as possible.

This can include helping people to access financial, emotional, psychological and social support as well as providing them with information on managing their lifestyle, treatments and therapies available.

The NHS Long Term Plan makes a commitment that by 2021, where appropriate every person diagnosed with cancer will have access to personalised care including a full assessment of their needs, an individual care plan and information and support for their wider health and wellbeing. 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.

Our work includes developing guidelines for hospital trusts in Surrey and Sussex. These guidelines will ensure all cancer patients receive the same access to personalised care from the point of diagnosis and ensuring patients receive appropriate follow-up care after treatment, based on their needs.

We are working with commissioners and providers of cancer services to embed:

  • Holistic needs assessment – a questionnaire that patients complete at key points in their cancer journey. The assessment asks patients about their practical, emotional, spiritual and social needs are met and can inform their care plan.
  • Treatment summary – a record of a person’s cancer treatment that is completed by the secondary care (hospital) team at the end of treatment. It is shared with both the patient and their GP and can help inform the cancer care review.
  • Cancer care review – an opportunity for patients to discuss their cancer journey with their GP or practice nurse. Cancer care reviews will take place from the point of diagnosis to ensure all cancer patients have the right support in place, understand the services available to them and have an opportunity to ask questions.
  • Health and wellbeing provision – opportunities for patients to access health and wellbeing information and support both during and after their treatment. They may include information on diet and lifestyle, financial support or the long-term effects of treatment, as examples.

Personalised follow-up pathways

We are also working to ensure personalised stratified follow-up pathways for breast, prostate and colorectal cancer patients are in place in Surrey and Sussex by 2020.

The follow-up care each individual needs can depend on many factors including their cancer type, the effects of treatment, if they have any other health conditions and the level of professional involvement needed. The follow-up pathways ensure that at the end of treatment, patients will receive care that meets their needs.

For some people this may mean being supported to self-manage with fewer unnecessary face-to-face hospital appointments; instead they can receive care closer to home, with access to clinical support if they have any concerns. The decision as to which is the most appropriate follow-up pathway will always be taken in consultation with the patient.

As well as freeing up patient time and reducing unnecessary travel to hospital, these stratified follow-up pathways also enable cancer teams to free up capacity to care for new cancer patients.

In line with national ambitions, we introduced guidance on the follow-up pathway for breast cancer in March 2019 and are now working to ensure that from April 2020, two thirds of patients are on a supported self-management pathway. We are also developing guidance for prostate and colorectal cancers, to be in place by March 2020.

Developing a workforce to support personalised care

Surrey and Sussex Cancer Alliance understands and values the work conducted by our third sector colleagues.  We are proud to work in partnership with Macmillan and in 2018-19 they funded two personalised care clinical leads, a primary care clinical lead and a patient and public participation lead for Surrey and Sussex Cancer Alliance. These roles are integral to taking forward the personalised care work. We will continue to work in partnership with Macmillan to ensure that patients have access to the right expertise and support, including a clinical nurse specialist or support worker.

In addition, Surrey and Sussex Cancer Alliance has funded six dedicated personalised care project managers to support the six acute trusts in our area. Each project manager has a specific focus on personalised care interventions and the support self-management pathway for breast cancer.

Digital care

We need to look to the future to deliver the ambitions in the Long Term Plan and achieve true transformation. Several digital initiatives are underway within our Cancer Alliance.

Personal Health Records

We are working with Surrey Heartlands Health and Care Partnership and Sussex Health and Care Partnership to develop personal health records within each health system that will support cancer patients living with and beyond cancer

Inter-Reg I-Know-How

We are working in the capacity as an “observer partner” to support the Inter-Reg I-Know How Programme. The programme is a three-year EU project which aims to help employees living with cancer remain or return to work, and to help employers support their employees living with cancer.  It includes developing an interactive web platform, and providing job coaching for employees and a toolkit and training programme for employers.