Personalised Care

The Clinical Nurse Specialists (CNSs) work across 12 specialties and three divisions within the organisation. All CNSs are line managed by the matrons within the divisions and supported by the LCN in a professional capacity. The CNSs play a key role in the patient journey and patient satisfaction and are central to the implementation of the personalised care agenda.

The Cancer Care Co-ordinators (CCCs) work alongside the CNSs to improve care for patients and deal with non-complex tasks to allow registered practitioners to focus their expertise on managing the complex care needs of the patient. They support improvement in the patient pathway, timely diagnosis, patient experience and personalised care.

Personalised care is ensuring care is based on ‘what matters’ to patients and relatives and their individual needs. It ensures they have choice and control over the way their care is planned and delivered to ensure better outcomes and experiences. This includes care from initial diagnosis, living with and beyond cancer and supporting rehabilitation to enable people to return to work and/or a near normal lifestyle. It consists of key components which are Holistic Needs Assessment (HNA), End of Treatment Summary (EOT), Health and Wellbeing Clinics/Education events (HWB) and Risk Stratified Follow Up (PSFU) or Self Supportive Management (SSM).

The NHS Long Term Plan for Cancer states that “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.”

A Holistic Needs Assessment (HNA) ensures that people’s physical, practical, emotional, spiritual, and social needs are met in a timely and appropriate way, and that resources are targeted to those who need them most. A HNA is a conversation that allows them to highlight the most important issues to them at that time and this informs the development of a person-centred care and support plan. The CNSs play a key role supporting cancer patients and ensuring every patient is offered a HNA.

Personalised Stratified Follow-Up (PSFU) and Cancer Remote Surveillance (RMS)

The NHS Long Term Plan states that by 2021 patients who have completed their cancer treatment 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 is termed personalised stratified follow-up pathways (PSFU).

PSFU should be seen in the context of the broader Long Term Plan target to reduce overall NHS outpatient attendances by 30 million by 2023 through the introduction of Patient Initiated Follow Up (PIFU) across a wide variety of specialties. PIFU is what is known as supported self-managed follow up within PSFU.

The implementation of PSFU offers huge benefits to cancer patients and the NHS. PSFU improves patient experience and quality of life for people following treatment for cancer as well as making services more efficient and cost-effective. People with ‘low risk’ circumstances are no longer seen in clinics to be given ‘good news’ from surveillance scan/test results but receive the results by post or digitally. PSFU therefore requires digital systems designed to ensure that people can self-manage after treatment safe in the knowledge their cancer surveillance is being undertaken accurately and reliably. The key components of PSFU are demonstrated below:

PSFU is a vital part of improving patient experience but also helps with the serious challenges of capacity and demand. There are over 10,000 patients registered for PSFU across Cheshire and Merseyside and it is estimated that over 27,000 outpatient appointments have been released by moving patients onto remote follow up in 2022-2023.

WUTH have successfully rolled out PSFU for breast, prostate, colorectal, kidney and lung patients which has released consultant capacity for those patients who would have returned previously to routine follow up.

All our patients on PSFU are registered on the Trust portal giving them access to letters and bloods etc. which has also reduced additional phone calls. Our patients also have access to a support worker using the two-way messaging in the portal so do not have to wait for an appointment or telephone call to discuss a concern.

Patients who are risk stratified enrol on Supported Self-Management follow-up (SSM) and attend a health and wellbeing clinic. This is a model whereby patients manage their own follow-up with back-up from clinical teams as needed to limit risk and ensure a satisfactory patient experience closer to home. SSM has been defined as the “systematic provision of education and supportive interventions by health care staff to increase patients’ skills and confidence in managing their health problems and to support daily decision-making to improve health-related behaviours and clinical outcomes”. SSM has reduced medical led follow up and been well received by patients as providing the necessary information in relation to recovery, signs and symptoms to look out for, healthy lifestyle and taking back control of their future management.