Nurse talking to a patientThis section outlines resources and tools for professionals to deliver personalised care to patients.

Personalised care means giving patients more choice and control over their care, based on what matters most to them as individuals. 

Personalised Cancer Care is a partnership between people with cancer and their professional team, providing access to care and support that meets their individual needs from the moment they receive their cancer diagnosis so that they can live as full, healthy and active a life as possible.   

With partners, we have produced a patient information leaflet outlining the personalised care they should expect when undergoing cancer treatment.

A holistic needs assessment covers a wide range of topics such as physical and emotional wellbeing, but also social elements such as family, finance and work.  

It helps patients identify and prioritise what matters most to them and what they might need support with managing. 

Once completed, this assessment will help to guide the conversation with your patient to enable a personalised care plan to be developed.  This assessment should be offered around diagnosis and at other points on the cancer pathway. 

Macmillan Cancer Support has created a guide for professionals providing holistic needs assessments, care and support planning.

This online learning package from Guy's Cancer Academy guides professionals on conducting care and supports planning consultations and completing care plans following the completion of holistic needs assessments (HNA) by people with cancer.

Information and support should be made available to patients during and beyond cancer treatment, including:

  • emotional support;
  • coping with side effects;
  • physical wellbeing;
  • advice about money;
  • getting back to work;
  • making healthy lifestyle choices.

A list of information resources and cancer information centres on sites in South East London is available here.

It is good practice and a Quality and Outcomes Framework (QoF) requirement for all patients to receive a phone call from their GP within the first 3 months of diagnosis.

The Cancer Care Review should be undertaken by a GP or Practice Nurse. It is a QoF requirement that this takes place within the first six-12 months following diagnosis––. The review should include:

  • talking about the patient’s diagnosis and current needs and any worries they may have;
  • any extra support they might need;
  • a review of their medication;
  • Outlining access to other services they may need, such as counsellors, rehabilitation specialists or social prescribers.

At the end of a period of treatment, a patient should receive a Treatment Summary from their secondary care provider. A Treatment Summary will include:

  • The patient’s diagnosis;
  • the treatment received;
  • follow-up arrangements;
  • possible long-term effects or complications;
  • signs and symptoms to look out for;
  • details of who to get in touch with if the patient needs support or are worried about anything.

A copy of this should be sent to the patient’s GP.

The NHS Long Term Plan for Cancer outlines that “after treatment, the person 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.”

Personalised Stratified Follow-Up (PSFU) is a vital part of delivering world class cancer services to people while addressing the serious challenges of demand and capacity throughout cancer pathways.

The implementation of PSFU pathways provides better care and experience for patients. By reducing the amount of time that professionals spend seeing patients who are doing well after treatment, it also frees up professionals’ time to focus on other parts of cancer pathways, such as faster diagnosis and treatment, or those with complex post-treatment needs.

Having PSFU pathways means that when a person completes their primary treatment, they will be offered:

  • information about signs and symptoms to look out for, which could suggest their cancer has recurred;
  • rapid re-access to their cancer team, including telephone advice and support, if they are worried about any symptoms, including possible side-effects of treatment;
  • regular surveillance scans or tests (depending on cancer type), with quicker and easier access to results so that any anxiety is kept to a minimum; and
  • personalised care and support planning and support for self-management, to help them to improve their health and wellbeing in the long-term.

In South East London we are currently working with clinical teams and patients to roll out this method of follow up to breast, prostate, colorectal and head and neck cancer.

Guidance on implementing personalised stratified follow up pathways can be found on the NHS England website.

What is social prescribing and when can it be useful?

People affected by cancer have wider issues than can be solved with clinical treatments alone. For example, we might see people who have been experiencing loneliness or facing practical financial worries.

Social prescribing is a really valuable way for primary care to:
•    support people affected by cancer to manage their needs;
•    bring benefits to their health;
•    and, provide all of this in a way that is most appropriate for them.

The impact of life circumstances such as housing, employment, and environment on people's health and recovery from illness is well known. What is new, is that we now have models of care that can join up the different services to support people, enabling us to try and meet their non-clinical needs. Social prescribing is a central part of the drive towards personalised care, which aims to help professionals to consider all the factors affecting a person's health. This enables people to have more control over their own health and care, managing their needs in a way that suits them.

As this is a new service within the NHS, many practitioners will not yet be familiar with social prescribing services and their potential, and the sort of situations in which they can help. Therefore, this short resource from Guy's Cancer Academy provides a comprehensive but concise, overview of the what, why and how of social prescribing in your context.

People living with cancer have varied needs and cancer can affect all aspects of life, from relationships to work or finance. Cancer can have a huge emotional impact on the individual and those around them.

Social prescribing is now available in all areas of south east London enabling people to access help with facing  difficulties close to home.

Contact details vary by area. In Bexley, Greenwich, Lambeth, and Lewisham referral can be made directly to the SP team. In other areas referrals must be done via GP services.

Bexley

Referrals can be made online at the Bexley Voluntary Service Council website.

Greenwich

The Live Well Greenwich line is a free helpline staffed by local, trained health and wellbeing advisors for signposting and support to live well. Tel: 0800 470 4831. Monday–Thursday, 8.30am–7.30pm; Friday, 8.30am–5.30pm; Saturday, 9am–12 noon. A message can be left outside of these hours.

Lambeth

If you are a professional, please visit AgeUK Lambeth or email mycommunity@ageuklambeth.org for advice before making a referral that requires an immediate or urgent response. If someone needs urgent support please advise them to contact the Support Line: 0333 360 3700, Monday–Friday, 9am–5pm (excluding bank holidays).

Lewisham

One Health Lewisham works with the Primary Care Networks to deliver a social prescribing service for people living in the borough of Lewisham. They do this with support from the voluntary and charity sector and local authority. You can also call 07508 215139. 

 

Patients can't directly refer in Bromley and Southwark; these have to go via their GP. These links provide details of some of the services offered by link workers.

Bromley

Visit Bromley Well's website or Tel. 0808 278 7898, Monday–Saturday, 9am–5pm.

Southwark 

North: Quay Health Solutions, Monday–Friday, 9am-5pm, Contact for information: qhs.socialprescribing@nhs.net 

South: Improving Health Limited, Monday–Friday, 9am-5pm, Contact for information: ih.socialprescribers@nhs.net 

Quality of life can be about a patient’s emotions, social life, money, or physical wellbeing as understanding the impact cancer has on lives will help improve our quality of care. A patient will receive the Cancer Quality of Life Survey from NHS England either electronically or by post 18 months after their diagnosis. Find out ways you can help promote the survey to patients.

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