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Cancer Survivorship: Transforming
how we deliver cancer care
Catherine Neck
Macmillan Cancer Rehabilitation/
Recovery Package Project Lead
My Role
• Funded by Macmillan to assist clinical teams
to process map and redesign pathways of care
across ASW region
• Involves the introduction of the ‘Recovery
Package’ into the pathway
• Supports teams to adjust to new ways of
working that are better for the patient and
result in increased clinical capacity
• Reduces unnecessary waste in the system
Cancer Pathway Redesign
• Most cancer patients are followed up for years
post treatment
• Most recurrences are detected outside of followup clinics
• If we redesign the pathways we can improve
patient experience, allow patients to play an
active role in their care and improve clinic
• Improved clinic capacity allows more time to see
NP’s and provide appropriate support for
complex patients
The Recovery Package
The Recovery Package
Stratification of patients for follow-up
Holistic Needs Assessments
Health & Wellbeing advice
Treatment summaries
Remote Surveillance
Cancer Care reviews
Improve Information and Support at
the outset
• Prehabilitation – encourage patients to take
an active role in improving their outcomes at
the start
• Provide a clear pathway of care from the
outset. Manage patient expectations
• Provide early health & wellbeing advice
around consequences of treatment, physical
activity, nutrition, work & finance support,
emotional support
End of Treatment
• Holistic Needs Assessment including Care Plan
• Provide clear and comprehensive information
to the patient and GP – Treatment Summary
• Support the patient to self-manage by being
able to identify signs and symptoms of
recurrence and providing timely open access
• Identify and act on early negative
consequences of treatment/ late effects
UHB Prehab Pilot
• Commenced Nov 2013
• OG patients seen at beginning of pathway by
Macmillan Cancer Support Worker
• Home exercise programme with weekly phone
review. Support offered for other issues – work,
finance, emotional support etc
• Positive results: improved physical function,
reduced LOS, positive patient experience
• Aiming to extend pilot to other sites – UGI and
other disease sites
Contact Details
If you and your team want support to process
map and look at pathway redesign please
contact me on:
[email protected]
07730 286356