Under the NHS Long Term Plan, all trusts that provide care for patients with breast, colorectal and prostate cancer had to put in place a person centred follow-up protocol and IT remote monitoring systems by March 2021, with the aim of transforming care to ensure individuals with cancer received follow-up care that best addresses their needs.

Cancer patients will be assigned a Clinical Nurse Specialist (CNS) who they can contact for advice and support, so any concerns will be quickly addressed. This approach is set out in our regional guidance (as per the links below).

Dr Christopher Scrase, Macmillan Consultant Clinical Oncologist at East Suffolk and North Essex NHS Foundation Trust and Macmillan Clinical Lead for Cancer, Suffolk and North East Essex ICS, said:

“We need to address the fact that across the East of England, there is variation in how follow-up care is provided to individuals who have completed their cancer treatment. Our new approach will mean patients are more in control of their follow-up treatment, tailored to their own specific needs, with necessary support from their hospital and wider support services.

This patient centred approach is in line with NHS England’s published Long Term Plan, which calls for a greater focus on promoting wellbeing, recovery and empowerment to provide individuals with information and confidence to have an active role in their care.”

The Clinical Lead for the East of England Cancer Alliance said:

"Due to the effectiveness of breast, colorectal and prostate cancer care, more people are living longer after the completion of their treatment, and we have had to consider how best they can be supported. Our new guidance puts a greater emphasis on helping patients to look after their own long term health and wellbeing and knowing what to do if they have any concerns following their treatment. Having specialist nurses available and in some areas community cancer nurses, means patients can be reassured that an appropriately trained health professional is on hand to help them."

Mr Vivekanandan Kumar, Consultant Urological Surgeon (Cancer Lead) for Norfolk and Norwich University Hospital said:

"The recently launched guidance developed by us on behalf of the East of England Cancer Alliances empowers patients to take control of their health needs, schedule follow-up tests, seek support from trained health care professionals and more importantly receive appropriate specialist help when concerned in a timely fashion”. 

Next steps for implementation:

Please find below a number of relevant documents including project plan templates which seek to provide a standardised approach for the implementation of breast, colorectal and prostate PCFU pathways within each trust. The documents below also include guidance, GP and patient leaflets and the NCSI (2013) How to Guide which provides trusts with additional practical guidance.

If you are interested in any of these documents or guidance please contact the general enquiries mailbox at:

england.eoecancerallianceteam@nhs.net

PCFU documents for breast cancer care: 

Guidance (Feb 2019) - breast cancer PCFU pathway implementation guidance

GP template leaflet (Feb 2019) - for patients with early breast cancer

Patient template leaflet (Feb 2019) - for patients with early breast cancer

A talk through the PCFU guidance for breast cancer patients. 

PCFU documents for colorectal cancer care

Colorectal PCFU Guidance (Dec 2019)

Template GP Leaflet (Dec 2019)

Template patient leaflet (Dec 2019)

PCFU documents for prostate cancer 

Regional guidance (Oct 2020)

Clinical Management Protocol Guidance slide deck (Oct 2020)

Patient Leaflet (Sept 2020) 

Living with and beyond cancer: Implementing personalised stratified follow-up pathways A handbook for local health and care systems. 

Macmillan (Oct 2019) Providing personalised care for people living with cancer - a guide for professionals providing holistic needs assessments, care and support planning.

Health and Wellbeing Information and Support (HWBIS) for people affected by cancer – secondary care self-assessment checklist:

The NHS Cancer Programme has worked with its Patient and Public Voices Forum and Cancer Alliances to co-produce this team self-assessment checklist which will ensure comprehensive and accessible HWBIS is provided for all people affected by cancer from diagnosis onwards. The purpose of this team self-assessment checklist is to help identify gaps in the provision of HWBIS across cancer pathways.
 
 Checklist Comms Pack
 Self-Assessment Checklist
 Self-Assessment (Excel spreadsheet)

Band 4 Support Worker Core Competency Framework and Checklist:

The East of England Cancer Alliances have worked collaboratively with Macmillan and Cancer Research UK (CRUK) to produce these documents.  They are recommended for Band 4 Cancer Support Workers who have been recruited to support delivery of the Personalised Care Package (formally known as the Recovery Package) and Patient Centred Follow-Up programmes within trusts across the East of England. 

East of England Cancer Alliances - Support Worker Core Competency Framework