Primary Care led and delivered follow-up of prostate cancer patients: the model for the future

1. Primary Care led and delivered follow-up of prostate cancer patients: the model for the future Sarita Yaganti Project Lead Service Improvement Cancer Commissioning Team West and South London

2. Cancer Commissioning Team: West & South London 20 CCGs 17 Trusts 5 million people (ONS) 3 ex-Cancer Networks 2 CCT patient groups 2 CSUs 1 Integrated Cancer System (the London Cancer Alliance)

3. The London cancer landscape • Reconfiguration of Cancer Networks and Pan London Teams – 5 became 3 and soon 3 will become 1 • 2 Integrated Cancer Systems (provider) - London Cancer (North and North Central London) - London Cancer Alliance (North West and South London) - pathway groups (one for each tumour site) • 5 year cancer strategy for London being developed • Pan London Living with and Beyond Cancer work stream in place

4. What we know about current follow-up • Variation: • in follow up protocols across the geography • in the content of the follow-up consultation • information give to patient • patients expectation and understanding of treatment • Willingness of patients to have follow up but want a “cancer specialist” in primary care • CCGs Care Closer to Home agenda highlights the potential for delivering primary care-led and delivered follow-up systems

5. Our ambition for follow-up • No “one-size fits all” follow-up pathway • Ensure patient choice can be exercised and patient experience is enhanced • Through training and education, we can assist primary and community teams to position themselves to provide care closer to home • Quality standards for follow up pathways are to be reflected in future commissioning arrangements • To continue to work collaboratively with patients, health professionals, cancer charities to benefit the ongoing development and improvement in follow-up cancer care

6. Our aim for this project ...is to examine the evidence to discover and agree the best practice follow up of suitablemen living with and beyond prostate cancer in primary care and to recommend commissioning options for service delivery models.

7. Project objectives – the why • To provide patients living with prostate cancer a safe, comprehensive follow-up service delivered by primary care • Ensure care is tailored to patient's holistic needs (namely psycho/sexual/social) and access to support services is available and equitable Employ 2 Band 8a Nurses to: • To identify what is needed to provide an appropriately skilled primary care workforce to deliver this model • To enable practice nurses to support patients living with and beyond a prostate cancer • Testing and evaluating a model of care

8. The Process – the how Supported by the CCT, two Band 8a nurses to take the project forward (recruitment in process)

9. Key deliverables – the what • Clearly defined, costed follow up model for the target patient group • Establish data metrics for auditing • Clarify the infrastructure required in primary care to deliver the pathway • Set up/improve rapid access referral back into secondary care • To provide a locally accessible service for patients and ensure choice of follow up is given as standard

10. Challenges • Recruitment – second time round  • New world of CSUs = exciting, hair raising twists and turns at each corner! • Things that we took for granted i.e. employing clinical staff for clinical roles • Data, data, data : • Identifying data sources e.g. primary care v secondary care data • Coding – what coding? • Being very clear on what data you wantneed.

11. The future • Developing ways of providing patient access to specialist clinical support within primary care • Established “key worker” policies for follow-up patients • Clear understanding of costs of different follow up pathways • Peripatetic workforce – promoting shared resources between practices • Continue to evaluate services by using consulting with those that are a part of the service – patients/providers/professions • Work with patients on what will enable them to be open and honest about how the emotive side to cancer effects them so that holistic needs can be met • Learn from each other.....so.....

12. Let’s talk... Sarita Yaganti: Project Lead, CCT North West & South London sarita.yaganti@nwlcsu.nhs.uk Barbara Gallagher: User Involvement Lead, CCT West & South London b.gallagher@nhs.net proudly supports