Asessment, Care Planning, Followup, Post-treatment Care

1. Ciar�n Devane - Chief Executive Asessment, Care Planning, Followup, Post-treatment Care 

2. The vision is to provide answers to issues patients identify �So what exactly has been done to me?� �What happens next?� �Why am I having these appointments?� �How will this medical / emotional / financial / practical / spiritual issue be addressed?�

3. Much of the thinking post Think Tank is unchanged Activities to include the development of: Treatment Record Framework. Risk Stratification framework / tool Cancer Survivorship Assessment tool Survivorship Care Plan Primary Care Cancer Care Review Framework/ guidance/ QOF Communication and co ordination of care ( people and technology)

4. There are good existing models which we want to pilot and evaluate further

5. Deliverable 1) Treatment Record Framework �So what exactly has been done to me?� ensure a single record which is intelligible to the patient exists and which is the basis of conversations �about the patient's care

6. Deliverable 2) Assessment and Care Planning Framework �What happens next?� ensure that post-treatment care is correctly and holistically assessed, and that clarity exists on delivering that care

7. Deliverable 3) GP Review and Recall System �Why am I have these appointments where nothing happens?� ensure appropriate, patient- specific, primary care oversight of cancer survivors

8. Deliverable 4) models of care for immediate post-treatment �How will this medical / emotional / financial / practical / spiritual issue be addressed?� tailored to the individual patient need. triaged pathway driven

9. Thinking we have yet to do . . . Pilots identified so far have been based on Expressions of Interest not Commissioned � does this leave gaps ?? Stepping back, what should things look like in 5 years ?? What is the policy, financial, workforce implication ?? How do we really link in non-NHS services ?? What about follow-up by secondary care ??