On behalf of SWAG Alliance 1 Living With amp Beyond Cancer Personalised Care SWAG Colorectal CAG Update By 2021 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 ID: 1041116
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1. 5th June 2019Catherine Neck, Macmillan Cancer Rehabilitation/ LWBC LeadOn behalf of SWAG Alliance1Living With & Beyond Cancer (Personalised Care): SWAG Colorectal CAG Update
2. By 2021, 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. After treatment, patients 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 stratified follow-up approach will be established in all trusts for breast cancer in 2019, for prostate and colorectal cancers in 2020 2NHS Long Term Plan
3. From April 2020:All breast, colorectal and prostate cancer patients from diagnosis (including secondary cancer) to have access to personalised supportApproximately two-thirds of patients who finish treatment for breast cancer to be on a supported self-management follow-up pathway and from diagnosis All Alliance Trusts to have in place protocols for stratifying the follow up of prostate and colorectal patients and systems for remote monitoring for these patients and from diagnosis3NHSE requirements for Personalised Care
4. Introduce remote monitoring systems for breast, prostate and colorectal Support commissioners with evaluation to inform an options appraisal, which will support decision on the future delivery of personalised care and support across the AllianceContinue collection of metrics that demonstrate patient experience and number of patients covered4SWAG LWBC Implementation 2019/20
5. We will be funding the set-up costs of remote monitoring systems from Alliance funds in 2019/20 (perhaps My Medical Record) We had thought that we might use some of our Alliance funding for 2019/20 to support CCGs to embed personalised care in recurrent funding – but both regional and National team were uncomfortable with this approach.The risk to sustainability of the LWBC programme has been raised with national team and discussions are ongoing. 5Remote Monitoring & Ongoing Sustainability for LWBC
6. At end of treatment all patients to receive a CNS review which includes the following:Holistic Needs Assessment and Care PlanBooking onto a Health & Wellbeing Clinic. If patient has already attended an early H&WB clinic then to be given site specific advice about signs and symptoms of recurrence and possible late effects of treatmentCompletion of Treatment SummaryPatients are then stratified into one of the following follow-up pathways. N.B. Patients should be reassessed and move freely between follow up pathways as their condition or needs change:Supported self-management pathway with routine surveillance and open accessShared Care Complex case management Discharged to GP care 6SWAG Colorectal Stratified Pathway
7. Patients who are able to understand and engage with processNo active disease/ serious/ uncontrolled symptoms from treatmentCan be for all stages of colorectal cancer (primary)All bloods, CTs, colonoscopies undertaken as per protocol7Self-Management with Open Access:
8. Patients requiring physical examinationNurse-led clinic for those unable to engage with self-management pathway i.e. due to cognitive or psychological issuesTrials Patients (should be on a pathway that meets stipulations in trial protocol)8Shared Care:
9. Serious uncontrolled symptomsComplex management or intense surveillance required i.e. following metastatic resections or T1 polypectomy’sPalliative patients receiving treatmentTrials patients (or on shared care pathway)9Complex Management via MDT:
10. Very frail patientsPatients for who no further active treatment would be offeredNot requiring further scans or blood tests10Discharge to GP:
11. Normal Results:Results reviewed and patient informed via letterHolistic Needs Assessment (paper copy and electronic link) sent with CT results at 1 and 2 yearsPatient informed to make contact if help is needed and given reminder of next test dateReminder of signs and symptoms given to patient11Self-management pathway process
12. Abnormal Results / Concerns / Symptoms:Open access into system within 2 weeksFurther diagnostic tests as requiredMDT reviewOPA12Self-management pathway process
13. Need to understand current position of teams against this pathwayWhat steps are needed to move towards delivery of this pathway?13Discussion/ Next Steps: