Personalised Care

Net and Pt.pngCheshire and Merseyside Cancer Alliance is committed to ensuring all people diagnosed with Cancer are able to recieve Cancer care in a personalised way.   

The Cancer Alliance is responsible for leading the local delivery of the national cancer strategy, which outlines the vision for the transformation of cancer services.  This vision is realised through working with all partners on the pathway and by addressing a range of key priority areas.  One of these priority areas is implementing personalised stratified follow-up for patients living with and beyond cancer.

Personalised Stratified Follow Up (PSFU)

Personalised Stratified Follow Up is a key feature of the national agenda.

Achieving World-Class Cancer Outcomes

The national strategy outlines recommendations specifically aimed at meeting the needs of people living with and beyond cancer (LWBC), particularly at the end of treatment with an emphasis on tailoring care to patient needs by providing care in line with the recovery package and stratified follow up pathways.

NHS Operational Planning and Contracting Guidance 2019/20

National guidance promotes stratified follow up pathways to be developed and in place for breast, colorectal and prostate by March 2020.

NHS Long Term Plan

NHS Long Term Plan identifies the importance of digitising outpatient care including remote monitoring and focusing on empowering patients to self-care.

Personalised Care Support Tools

Personalised Care Support Tools are 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.

Outlined below are the five key elements for embedding personalised care:

  • Holistic Needs Assessment (HNA)
  • Personalised Care & Support Plan
  • End of Treatment Summary
  • Health and Wellbeing Information and Support
  • Personalised Care Quality Group

Embedding personalised care includes:

  • The patient is invited to complete a holistic needs assessment (HNA) as part of the end of treatment care plan
  • Cancer support worker ensures HNA priorities are addressed and can include making referrals to relevant community services and support
  • Patients are requested to complete Health MOTs regularly to continually assess and monitor progress, and update the changing needs of the patient
  • Health and wellbeing support covers:
    • Support to register and access the remote monitoring platform
    • Healthy lifestyle advice
    • Role of Cancer Support Worker
    • A patient-focused education booklet which outlines PSFU process specific to the cancer pathway, self-care and on-going support available

Key Achievements in Cheshire & Merseyside

PSFU has successfully been implemented across ten trusts in nine breast units, six colorectal units and eight prostate units as outlined below:





Aintree University Hospital*

Countess of Chester Hospital NHS Foundation Trust

March 2020

The Royal Liverpool and Broadgreen University Hospitals NHS Trust*

St Helens and Knowsley Teaching Hospitals NHS Trust

March 2020

Warrington and Halton Hospitals NHS Foundation Trust

Wirral University Teaching Hospital NHS Foundation Trust

Southport and Ormskirk Hospital NHS Trust

No Breast service in place

Mid Cheshire Hospital NHS Foundation Trust


East Cheshire Hospitals NHS Trust


The Clatterbridge Cancer Centre NHS Foundation Trust


Benefits of PSFU

Benefits of PSFU

  • A treatment plan tailored to the patient's priorities and requirements
  • Increased skills to self-care
  • Reduced expenses associated with attending outpatient appointments (including loss of income)
  • Better safety netting compared to the traditional system as the patient retains direct access to care team
  • Timely access to their results and care team
  • Single point of access via the CSW
  • Promotes deploying personalised care as per the NHS cancer strategy
  • Advances the 'digital first' and PSFU agenda as per the Long Term Plan
  • Enhanced ability to audit and monitor the quality of care
  • A decrease in variation of care through the use of protocols
  • Efficiencies gained through a decrease in face to face out-patient appointments
  • High satisfaction rates reported by the teams and in particular the CSW's
  • A large proportion of the consultant and CNS administrative workload such a follow- up calls and patient queries are attended to by the CSW
  • The new role of CSW is a valuable addition to the team with core skills to increase patient empowerment and activation which can be applied to other care pathways
  • Clinical capacity released through PSFU can be redistributed to improve quality of care and higher value clinical activities
  • Clinical time can be redeployed to activities such as diagnosing more new patients and reducing waiting times; supporting more complex patients; and more clinics for elective care and procedures

Benefits of PSFU: Clinical Time Redeployed

A key benefit of PSFU is clinical time (of consultants and nurses) is released and can be redeployed for other activities as seeing new cancer patients and conducting related procedures.  Below is an estimate of the potential out-patient (OPA) time which was made available for other activities for the Trusts and pathways which implemented PSFU.

Case Studies

Liverpool University Hospitals NHS Foundation Trust is a specialist provider of prostatectomy for Cheshire and Merseyside.  The typical follow-up treatment post-surgery for a patient involves undergoing a diagnostic test every four months and a subsequent outpatient appointment to discuss the results of the test.  Over the usual follow-up period of five years, this can equate to over 12 outpatient appointments the patient needs attend, often with long travel times.

PSFU was introduced for Urology in April 2018 at the Trust and now all patients who meet the clinical criteria are transitioned to the PSFU pathway of care once the consultant makes the referral.  In line with the PSFU patient journey developed across CMCA, the patient is supported by a dedicated CSW with the option to attend a group health and wellbeing event to meet other patients and learn how to use the remote monitoring platform, My Medical Record (MMR).  The CSW makes referrals for the patient to relevant community and wellbeing services in line with the holistic needs assessment and remains the patient's single point of contact for specialist care.

Results of implementing PSFU have been beneficial in terms of patient and clinician experience, quality of care realising efficiencies.  Unless clinically indicated, all patients have chosen to remain on the PSFU pathway.  Feedback on the service is excellent and includes patients valuing the time and money it has saved them (by not having to attend outpatient appointments), the assurance of a named individual for support i.e. the CSW, and peer- support opportunities.  The estimated clinical capacity which has been able to be redeployed for every patient who has been transitioned to PSFU is equivalent to 5349 outpatient appointments.  This has supported additional high-value activities such as 28 additional prostatectomies and 13 additional renal related surgeries to be conducted in 2019.

" I am extremely enthusiastic about the role and I feel it is a privilege to support patients through this service.  Patient feedback on this service or remote surveillance is always positive - patients find it easy to navigate, very accessible and are so relieved and have so much more time freed up by not having to attend in-person follow-ups"

Olwen Teare, Cancer Support Worker

Southport and Ormskirk Hospitals NHS Trust introduced PSFU for colorectal cancer in May 2015.  Today all patients who meet the clinical criteria are transitioned to the PSFU pathway, and this includes patients who were initially started on the traditional out-patient pathway of care.  In line with the PSFU patient journey developed across CMCA, the patient is supported by a dedicated CSW with the option to attend a group health and wellbeing event or personal education session to obtain the knowledge and skills to advance their recovery and wellbeing, and use the remote monitoring platform, My Medical Record (MMR).

PSFU has yielded beneficial results in terms of patient and clinician experience, quality of care productivity.  Unless clinically indicated, all patients have chosen to remain on the PSFU pathway.  Feedback from patients attending the health and wellbeing events has been overwhelmingly positive with the majority strongly recommending the value of attending these events and using MMR (as per patient surveys conducted at events).  There has been an increase in the deployment and recording of the personalised care package including an increase in the number of end of treatment summaries and Holistic Assessments being completed.

The estimated clinical capacity which has been able to be redeployed for every patient who has been transitioned to PSFU is equivalent to 1250 outpatient appointments (May 2015 to July 2019).  This has supported additional high-value activities such as adding new patient clinics.

" I see first hand how cancer care is improving by personalising care to meet the multitude of needs that need to be addressed throughout post-treatment surveillance.  Clinical needs and diagnostics now follow an optimal pathway with results being relayed to patients in a more timely manner reducing the anxieties that can occur.  The role of the support worker allows continuity of care and better relationships between acute primary care settings.  Patients feel empowered because they know there is a support network that is easily accessed if its ever needed.  Education plays a huge part in a patients ability to self manage and through stratified follow up we can to deliver a tailor-made educational package to all patients giving them the means and knowledge to ensure that they are both mentally and physically well.  I am incredibly proud of what I do and feel this role is extremely rewarding, it is a privilege to be involved with the future of cancer follow up and personalised care and the improvements being facilitated across our Cancer Alliance".

Cassandra Garner, CSW

Reflection & Top Tips

Change at Scale

  • An agreed set of protocols used across CMCA
  • A standardised specification for health and wellbeing support rolled out across CMCA
  • Peer-support leveraged to share learning and solutions for an operational roll-out

A Personalised Care Quality Group

  • Advanced best practice guidelines through a CMCA wide group with representatives from primary care, secondary care, Macmillan, local voluntary hubs and patient groups

The Cancer Support Worker (CSW) Role

  • Develop a standardised  Job Description (JD) across CMCA
  • Comprehensive training programme developed and provided to each CSW to develop required core competencies and skills
  • Clinical nurse-led mentorship
  • Regular CMCA wide CSW forums to harness peer-support and learning

Cancer Alliance led Innovation

  • Project management capacity at CMCA to coordinate and support PSFU roll-out across the Alliance provider trusts
  • Clinical capacity to develop the CSW role and lead development of cancer-specific protocols
  • Strong executive leadership

Harness enthusiasm of early adopters to support Alliance wide roll-out

  • A key role of the CA is to facilitate the networking and knowledge transfer between Trusts and clinical champions

Enabling IT is a critical success factor

  • Involve the local IT and IG leads in the PSFU project team
  • Build insufficient time to secure IG approval and related IT integration within the project plan
  • Recommend investing in full integration between local PAS/diagnostic platform and the remote product



Next Steps for Cheshire & Merseyside

Next Steps

In line with the national cancer strategy and NHS Long Term Plan, CMCA aims to continue to develop and embed PSFU for cancer across the provider Trusts and support other Cancer Alliances with this initiative

  1. Continue to embed PSFU for cancer for breast, prostate and colorectal pathways across all Alliance provider Trusts
  2. New clinical pathways for PSFU under development for haematology, gynaecology and HPV (advanced colorectal)
  3. Support sustaining the service by local commissioning and cease reliance on Cancer Transformation Funding
  4. Developed a financial impact tool to support commissioners and provider Trusts to devise a local, feasible payment mechanism