Personalised Care

Net and Pt.pngCheshire and Merseyside Cancer Alliance is committed to improving the experience of all people living with and beyond cancer (LWBC), and has a well-established programme of improvements to ensure that people affected by cancer are able to make the most successful recovery possible. In 2018/19 the LWBC Programme Team has focused on four specific areas for improvement.
These improvements include:

  • Increasing access to the “recovery package”
  • Increasing access to cancer specific rehabilitation 
  • Improving patient experience of the GP Cancer Care Review
  • Implementing risk stratified follow up pathways

Key achievements in Living With and Beyond Cancer for 2017/18

  • Increase in the number of patients receiving Holistic Needs Assessment at diagnosis from baseline of 30% to 42%
  • Increase in the number of End of Treatment Summaries from a baseline of 7% - 26% (Oct 17 – May 18)
  • Increase in the % number of patients attending Health and Wellbeing events from 14% - 30% (Oct 17 – May 18)
  • 1102 breast, colorectal and prostate patients registered onto remote surveillance as part of their supported self-management follow up (Oct 17 – May 18)
  • All areas of the recovery package have achieved their increasing trajectory targets for three consecutive quarters.

Recovery Package

The Recovery Package is a series of interventions designed to support Cancer patients from their diagnosis, through treatment and beyond, to enable the best possible clinical and personal outcomes from their experience.

The Package consists of four key elements:

Holistic Needs Assessment (HNA)

The HNA is a simple questionnaire that is completed by the patient and covers all areas of their health and wellbeing. From the responses provided, the keyworker will signpost the patient to sources of support and information so that practical, physical, spiritual and social needs are met in a timely and appropriate way.

HNA allows the person with cancer to highlight the most important issues to them at that time, which will inform the development of a care and support plan with their nurse or key worker.

Health & Wellbeing Events

These events are designed to help people affected by cancer find about the support available to them during and after cancer treatment.

This can include information on:

  • Benefits and other financial support
  • How to get back to work
  • Diet and lifestyle
  • Long-term side-effects of treatment
  • Specific cancers
  • Local services

Events will be held in local hospitals, community or primary care venues.

End of Treatment Summary

 A Treatment Summary is a document (or record) completed by secondary care professionals, (usually the multi-disciplinary team (MDT)) after a significant phase of a patient’s cancer treatment. It describes the treatment, potential side effects, and signs and symptoms of recurrence and is designed to be shared with the patient and their GP.

Cancer Care Review

There is a discussion between the patient and their GP or practice nurse about their cancer journey. It helps the person affected by cancer understand what information and support is available to them in their local area, and to encourage the patient to open up about their cancer experience and enable supported self-management.

Risk Stratified Follow Up Pathways

Risk stratified pathways are a way of making sure that patients who have completed their cancer treatment have a choice about the way in which their aftercare is delivered.

Eligible patients may be selected to a remote surveillance pathway, which no longer requires them to attend unnecessary outpatient appointments. A support worker acts as the coordinator of their follow up investigations, and acts as the first port of call should the patient have any concerns. This method of follow up has been rolled out in Breast, Colorectal (bowel) and Prostate cancer in Cheshire and Merseyside. 

Case Study: Holistic Needs Assessments

Jeanette Oxton is a Cancer Support Worker (CSW), working in the Head and Neck Cancer department at Clatterbridge Cancer Centre. As a CSW she works as part of the Head and Neck Team, liaising closely with Cancer Nurses Specialists to support patients and their carers.

Jeanette will arrange to meet each patient at the beginning of their treatment to offer a Holistic Needs Assessment (HNA) which is a conversation designed to focus on any concerns the patient may have. The HNA gives the patient the opportunity to think about any concerns they may have and discuss possible solutions.  These concerns may be:

  • Physical
  • Emotional
  • Practical
  • Financial
  • Spiritual

For many people, the meeting takes about 30 minutes but can take longer. Should patients require ongoing support, further appointments can be arranged.

“I am there for the patient through their treatment and if they are not certain about whether they want to undertake an HNA, I leave my contact details with them in case they decide to at a later date.”

Many patients find having an HNA useful as it can help focus on what is important to them at this time and identify what help may be available. After the HNA is completed, Jeanette and the patient will discuss any concerns and collaboratively identify a personalised written care plan. The patient is offered a copy of the plan to take away with them and if agreed, it may also be shared with other members of their healthcare team to help deliver or improve their on-going care.

Permission is requested from the patient to store the care plan securely, either electronically or as a paper copy along with other health records. This can then be reviewed whenever necessary.

The care plan may include ideas to help manage any concerns and if needed signpost the patient to organisations that may provide support such as the Macmillan benefits team, a counsellor, a speech therapist or a dietitian.

 “The HNA allows our patients with cancer to highlight the most important issues to them at that time, which will inform the development of a care and support plan.  It empowers the patient and also helps them get on top of any problems sooner than later.”

Into Recovery

The discussion also helps patients to think about what happens when they finish treatment, and moving forward how to put those support mechanisms into place.

It gives patients the opportunity to make future contacts, undertake the groundwork and to continue building upon those foundations whilst having treatment. We aim to support patients to develop coping strategies and discover local services and activities to aid their recovery once their treatment is completed.

Pictured is Jeanette undertaking a Holistic Needs Assessment with patient Alexander Graham, who has now completed his treatment.