Download New models of Follow up care

Somerset, Wilts, Avon and Gloucester Cancer Services
Living with and Beyond Cancer
Dr Dorothy Goddard
Macmillan Associate Medical Director for Cancer
RUH
Somerset, Wilts, Avon and Gloucester Cancer Services
The problem: increasing demand
Increasing
number of people developing cancer
Increasing
number of survivors
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Somerset, Wilts, Avon and Gloucester Cancer Services
The problem: unmet needs
Conventional
follow up not meeting people’s needs
Recurrent
or new disease not picked up at routine
follow up visit
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Somerset, Wilts, Avon and Gloucester Cancer Services
Cancer Survivorship
Living with and beyond cancer
Supporting
people from cancer diagnosis through
treatment and beyond…
 Includes
New
recovery and rehabilitation, (+/- pre-habilitation)
models of after care: supported self management
 Return
to specialist care
Supporting
people with active or advanced disease
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Somerset, Wilts, Avon and Gloucester Cancer Services
Recovery and rehabilitation
Survivorship
recovery package
 Holistic
needs
assessment and care
planning – with referral as
required
 Treatment
summary and
GP cancer care review
 Health
and well being
event
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Holistic Needs Assessment and Care Plan
National Cancer Survivorship Initiative
Electronic version
National Cancer Survivorship Initiative
Somerset, Wilts, Avon and Gloucester Cancer Services
Treatment summary
Essential
information for GP
 Developed
 Designed
by Macmillan GP’s
to inform GP primary care review
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Treatment summary and
care plan
Diagnosis:
Date of Diagnosis:
Organ/Staging
Summary of Treatment and relevant dates:
Treatment Aim:
Possible treatment toxicities and / or late effects:
Advise entry onto primary care
palliative or supportive care
register
Yes / No
DS 1500 application completed
Yes/No
Prescription Charge exemption
arranged
Yes/No
Contacts for re referrals or
queries:
Alert Symptoms that require referral back to specialist
team:
In Hours / Out of hours:
Other service referrals made:
(delete as nec)
Secondary Care Ongoing Management Plan: (tests,
District Nurse
appointments etc)
AHP
Social Worker
.
Dietician
Clinical Nurse Specialist
Psychologist
Benefits/Advice Service
Other
Required GP actions in addition to GP Cancer Care Review (e.g. ongoing medication,
osteoporosis and cardiac screening)
Summary of information given to the patient about their cancer and future progress:
Additional information including issues relating to lifestyle and support needs:
Somerset, Wilts, Avon and Gloucester Cancer Services
Moving On Day
Opportunity for survivors to meet
with professionals, ask questions,
meet allied organisations
Somerset, Wilts, Avon and Gloucester Cancer Services
Rehabilitation
Services
such as
 ‘Step
up’ chronic fatigue service based at RNHRD
 Exercise programme with ‘Aquaterra’ service
 Dietician
 Benefits / advice service
 Counselling services or Psychologist
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Somerset, Wilts, Avon and Gloucester Cancer Services
New models of Follow up care

Routine clinical follow up replaced by: Supported
self-management for all suitable patients with discharge from
clinical follow up on completion of primary treatment.
Risk stratified model of care
Somerset, Wilts, Avon and Gloucester Cancer Services
New models of Follow up care

‘Remote’ monitoring (eg blood markers, PSA
monitoring, CT scans, colonoscopies, mammography)

Requires effective IT systems to ensure surveillance tests
are done, results checked, patient/GP informed

Nurse/Allied health professional follow up/often by
telephone or at routine surveillance points »
»
such as mammography or PSA, CEA feedback
include routine Patient Reported Outcome Measures (PROM’s –
provide evidence of unmet needs or consequences of treatment)
Somerset, Wilts, Avon and Gloucester Cancer Services
Return to specialist care
Contact
Information to patient and GP – in hours / out
of hours
 Telephone
advice
 Return for clinical review
Support
for active or advanced disease / late effects
 Provided
in partnership with primary care
 Metastatic cancer nurse specialists
 Development late effects services
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Somerset, Wilts, Avon and Gloucester Cancer Services
Late effects

Some health and wellbeing issues attributed to
consequences of cancer treatment – such as:
Post breast cancer:
Menopausal symptoms
Osteoporosis
Pain
FATIGUE
Lymphoedema – arm and/or breast
Post colon cancer:
50% patients after pelvic
radiotherapy
- left with bowel problems
affecting quality of life
Post prostate cancer:
Erectile dysfunction
Post childhood cancer:
60% experience one or more late effects of treatment 10 years
following treatment.
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South West Strategic Clinical Networks
ASW Cancer Network Survivorship Group:
Identifying and meeting the diverse needs of cancer survivors
Aim:
To work collaboratively across the Network and Health Community involving all organisations
caring for cancer survivors: acute providers, primary care, clinical commissioning groups,
community services, charitable organisations and service users
Objectives:
To develop services within and across organisations to identify and meet the diverse needs of
cancer survivors
To develop a source of information for services available for cancer survivors
First steps:
To develop a work programme initially to support specific interventions such as health needs
assessments, end of treatment summaries and health & well being clinics.
To identify resource implications and process to support commissioning