Living with and beyond cancer
Secondary Care
The delivery of personalised care for cancer includes a combination of different interventions, which when delivered together, can greatly improve the outcomes and coordination of care, including better and earlier identification of consequences of treatment.
The interventions have been developed to assist people living with a diagnosis of cancer to identify their individual needs and support them to live well before, during and after treatment.
The key interventions of personalised care are:
- Holistic Needs Assessment and Personalised Care & Support Plan
- End of Treatment Summary
- Personalised Stratified Follow Up
- Cancer Care Review
- Prehabilitation
Scroll down to learn more and find out where to access further training and development on personalised care.
This video provides a short introduction to personalised care.
The Holistic Needs Assessment (HNA) is a paper or electronic document completed by patients and their clinical teams to help them both think about any needs or concerns they have.
Holistic Needs Assessment (HNA)
To develop a care plan, you will need to carry out an assessment of the person’s holistic needs to understand how to support them. There are various tools to assist with this.
It is a checklist or set of questions about physical, emotional, practical, financial and spiritual needs following a cancer diagnosis. It gives professionals a greater understanding of a patients needs and helps identify and address specific problems. Once discussed the answers form a care plan that outlines what was agreed and any contact details for organisations or services that could help. This can be shared with other health professionals including primary care.
You can offer an HNA at diagnosis, during treatment or after treatment has ended but you can undertake an assessment at any time if you feel it would help. It only takes about 30 minutes to complete and can help plan ahead – from diagnosis through to treatment and life after treatment.
Personalised Care and Support Plan (PCSP)
A PCSP ensures people’s physical, practical, emotional and social needs are identified and addressed at the earliest opportunity.
A Personalised Care and Support Plan will help you to:
- keep a record of conversations, decisions and agreed outcomes.
- understand a patient’s care and support needs, their life and family situation.
- know what is required to make the plan achievable and effective.
Patients should receive a copy of their PCSP.
An End of Treatment Summary is a short document completed (once treatment is finished) by the healthcare team, often the Cancer Clinical Nurse Specialist. It provides information about the diagnosis, side effects of treatment, signs and symptoms of recurrence and who to contact with any concerns.
It is shared with the patient and their primary care team to inform them of any actions required. The GP can then update the records and use the document as a basis for conducting the Cancer Care Review.
End of Treatment Summaries can be completed manually on paper or electronically on hospital clinical systems.
There is a specific SNOMED code associated with EOTS so they are easily identifiable on GP systems. Click here to view the codes👉SNOMED Codes Personalised Care
National guidance encourages stratification of patients onto follow up pathways based on risk. There is currently little evidence that routine follow-up identifies disease recurrence yet it is costly and time consuming.
There are stratified follow up pathways for breast, colorectal, gynaecological, prostate and head and neck pathways.
Patients should be stratified for follow up by their clinician following initial treatment based on clinical need. This ranges from professional led follow up for those at higher risk of disease recurrence to self management for low risk patients who following treatment will no longer have routine follow up appointments. Instead these patients are educated to self-manage their condition with back up from the clinical team and access to remote monitoring and re-entry pathways.
A Health Needs Assessment (HNA) is carried out and a Personalised Care and Support Plan (PCSP) drawn up to address the needs of these individuals aimed at minimising risk and support to manage on-going conditions.
The Cancer Alliance agreed stratified follow-up pathway model is below:
The Cancer Care Review (CCR) is a conversation between a patient and their Primary Care team about their cancer journey.
It is an opportunity for patients to:
- Talk about their cancer experience and concerns.
- Understand what support is available in their community.
After a cancer diagnosis, people may have lots of appointments and support from their hospital team. However, the Primary Care team is also there to help. To learn more about Cancer Care Reviews and the role of primary care click here 👉Cancer Care Review
Prehabilitation is a part of personalised care. It is a patient-centred, evidenced-based and multidisciplinary approach that prepares individuals with cancer for their treatment by optimising their physical and mental health.
Starting from diagnosis continuing through to treatment and rehabilitation. It aims to empower patients to take control of their health, build physical and psychological resilience and provide opportunities to develop healthy lifestyle behaviours to improve long-term health.
The Prehab Hub is an online resource developed by leading experts in the NENC designed to help healthcare professional prepare patients for treatment by improving physical and mental wellbeing.
It brings together expert advice on key areas such as nutrition, physical activity, sleep, psychological health, and managing chronic conditions, with practical tips and videos to make getting ready for treatment easier.
You can access the resource here👉The Prehab Hub
The Personalised Care Institute – a hub of education and resources for health and care professionals delivering personalised care. The institute offers a range of flexible ways to develop knowledge, skills and confidence to provide personalised care.
Macmillan have also developed the following Personalised Care modules
The PRosPer programme provides elearning on supporting people with cancer in personalised care and support planning, prehabilitation and rehabilitation. It also covers managing the consequences of cancer and its treatment, workforce development and service redesign.
Personalised Care: Peer Leadership Foundation – developed by the Personalised Care Group at NHS England and NHS Improvement (NHSE/I). A four week course to learn what personalised care is and how the whole population can benefit in England.
