Personalised Care: supporting those living with and beyond Cancer

To download the Cancer Information, Support and Wellbeing App for free, please click here for further instructions

What is Personalised Care and why is it important?

  • It means people have a choice and control over the way their care is planned and delivered
  • It is based on ‘what matters’ to them and their individual strengths and needs
  • It makes the most of the expertise, capacity and potential of people, families and communities in order to deliver better outcomes and experiences
  • It represents a new relationship between people, professionals and the health and care system; providing a shift in decision making that enables people to have a voice, to be heard and be connected to each other and their communities
  • It recognises the contribution of communities and the voluntary and community sector to support people and build resilience
  • It improves people’s health and wellbeing, joins up care in local communities, reduces pressures on NHS services and helps the health and care system to be more efficient
  • It helps people with multiple physical and mental health conditions make decisions about managing their health, so they can live the life they want to live, based on what matters to them, as well as the evidence-based, good quality information from the health and care professionals who support them
  • It recognises that, for many people, their needs arise from circumstances beyond the purely medical, and will support them to connect to the care and support options available in their communities

What are we doing at The Shrewsbury and Telford Hospital NHS Trust?

Here at The Shrewsbury and Telford Hospital NHS Trust, the Personalised Care Team are continuously working with teams, both within the Trust and externally, to develop resources and services to aid personalised care including:

  • Health Needs Assessment (HNA), supported by a Personalised Care and Support Plan (PCSP) if appropriate
  • Treatment Summaries
  • Health and Wellbeing Offers including Living Well Sessions and Living Well Videos
  • Working with colleagues in Primary Care to support Cancer Care Reviews
  • Embedding Personalised Stratified Follow Up (remote monitoring and self-management) pathways with a number of specialist teams
  • The development of Cancer Information, support and Wellbeing Guide
  • The development of the Cancer Support, Information and Wellbeing App

For more information, please click on each of the links below or please feel free to contact the team.

We are also involved with another number of different projects, all with a focus to improving patient experience, improving quality of care and ensuring that Personalised Care is offered from time of diagnosis, during treatment, and after this treatment ends.

The Personalised Care Team:

Leah Morgan – Personalised Care Lead  Cancer Improvement Facilitator

Katey Evans – Personalised Care Navigator

Why is Personalised Care so important?

There has been a lot of positive feedback about the treatment patients/people living with cancer received whilst at the Trust:

“Cancer treatment and care at SaTH is second to none – with efficiency, kindness, personal service and good communication”.

“Treatment at SaTH is world class – the staff are always available for questions and support”.

However, it also identified gaps regarding the after care:

“After care is a bit of an afterthought. We feel cast adrift after our treatment without consistent info and support. Who gets what afterwards is a lottery!”

“After care towards the end of treatment is perhaps the least understood part of the cancer services but as my family and I are finding, it is the most vital part and could be so much better”.

In response to this, the formerly known ‘Living With and Beyond Cancer Programme’ was formed to introduce the main interventions outlined by NHS England. These interventions aim to improve the quality of life of anyone living with cancer and their loved ones.

As the programme has developed, now recognised as the Personalised Care Team, we have taken pro-active steps to improve Personalised Care for those living with a cancer diagnosis as well as those around them who are supporting them. This has included developing a digital platform through the app, allowing access to information 24/7, at the right time for that person and working collaboratively with a number of charities, organisations and services to provide additional resources and support throughout Shropshire, Telford & Wrekin and Powys.

Please click on the tabs below for further information:

The app was launched by The Shrewsbury and Telford Hospital (SaTH) NHS Trust in July 2022 after recognising that information could be given via a digital platform, enabling people to access information at the right time for them. The app is free to download on Apple and Android devices and has been developed alongside professionals, organisations, services, and charities supporting those affected by cancer and people who are affected by a cancer diagnosis.

As well as being a resource for people living in Shropshire, Telford & Wrekin and Powys, the app can be downloaded for people who are supporting people following a diagnosis as well as other healthcare professionals across the county.

What information is on the app?

  • Welcome page about the hospitals and Cancer Services
  • News articles and stories of what is happening nationally and locally
  • Events happening throughout Shropshire, Telford & Wrekin and Powys
  • Living With and Beyond Programme
    • Information about Personalised Care
    • Social Media links (for the Personalised Care programme)
    • Health/Holistic Needs Assessment and Personalised Care and Support Plan
    • The Cancer Information, Support and Wellbeing Guide
    • Treatment Summaries
    • Living Well Sessions
    • Living Well Videos
    • Cancer Care Review in Primary Care
    • Person Centred Follow Up: the self-supported management pathway
  • Financial information about supporting you with money
  • Services and teams
  • Lingen Davies Oncology Centre
  • Community Support
  • … and much more

For more information or to suggest content for the app, please contact the Personalised Care Team on 01743 492424 or via email sath.lwbc@nhs.net. 

How to download the app

Click here for the Download Guide or scan the QR codes below to install the app:

For Android devices:

For iPhones or iPads:

Once you have downloaded the app, you must search for SaTH Cancer Services.

The Holistic Needs Assessment (HNA) is a meaningful conversation with a member of your team around what matters to you. It is well recognised that cancer can affect everyone in different ways. The HNA allows an opportunity for you to discuss any of these concerns with a healthcare professional.

Although there is a checklist covering a number of concerns, this is only a guide and it may be that you wish to talk about something different. During the conversation, the healthcare professional will listen to you and take appropriate action to support you with your concerns. This may mean referring or signposting you to a different person or team who will be in the best position to be able to help you.

If appropriate, the healthcare professional will create a Personalised Care and Support Plan which outlines the concerns you spoke about and what you agreed together in how to handle this concern. This may be actions that the healthcare has agreed to handle, or it may be actions that you have agreed to take yourself.

A HNA is normally offered to you by your team but HNAs and conversations can take place at any point you feel is necessary. Please ring your clinical team or your Cancer Care Navigator to speak with them if you have any concerns or questions. These concerns do not have to be about your clinical pathway; they can be anything that is bothering you or you need support with.

Download a copy of the HNA checklist used as a guide to help you with the conversation.

A Treatment Summary is a summary of care provided for the patient and their GP, with minimal jargon, produced by the health care professionals within the hospital that you are receiving treatment.

The Treatment Summary aims to empower you by giving you information about your care in a clear, straightforward way. It outlines what signs and symptoms to be aware of following treatment as well as who to contact should you have any concerns.  It also gives you information of further support and services that may be beneficial to you following your treatment, in addition to clear actions that will be taken by the hospital team and the GP in Primary Care.

It may be that you have not received this summary at the end of your treatment; please do not be concerned. You are still able to contact your team with any concerns or questions you have about your treatment and plan of care. The Treatment Summary is a project that is continuously being developed within the specialist teams in at the hospital.

If you have any further questions or wish to give any feedback about a Treatment Summary you may have received, please contact the Personalised Care Team on 01743 492424 or via email on sath.lwbc@nhs.net.

The Living Well Sessions are:

  • for anybody affected by cancer: the person living with cancer, family, friends or anybody else supporting someone living with and beyond cancer
  • free to attend at the right time for you
  • held at different community venues throughout Shropshire, Telford & Wrekin
  • available for you to attend as many times as you wish pre, during and post treatment
  • designed to offer support, advice and tips as to how to safely self-manage four topics away from the hospital setting
    • Fatigue
    • Emotional Wellbeing
    • Physical Activity
    • Nutrition
  • full of information about local and national services that you may benefit from
  • there to provide an opportunity for you to share your experiences and learn from others
  • an opportunity to ask non-clinical questions around the four topics

Please click here for a list of dates and venues.

Here are some comments from others who have attended a Living Well session:

“Excellent session – thank you. Good to hear other people’s accounts and experiences. You are not alone!”

“Brilliant and most useful”

“Really informative and interactive. Comforting in being with likeminded people who share similar concerns”

“I am a carer so found the event very useful for me and my wife”

“Was lucky to meet other family members to talk about how we help our relatives, partners and ourselves to cope”

“Excellent speakers .Good to have a patient story and hear from people at different stages of treatment”

“Very informative and informal Lots of useful tips and information, Well worth taking part”

“Excellent session – warm and welcoming. Very practical”

The NHS Long Term Plan for Cancer states that ‘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.’

Personalised stratified follow-up (PSFU) pathways are tailored to individual needs and aims to improve patient experience, provide better care, and deliver an improved quality of life for people following treatment for cancer alongside addressing the serious challenges of demand and capacity throughout cancer pathways.

PSFU pathways aim to reduce the amount of time that professionals spend seeing patients who are doing well after treatment. If you are being put on to this pathway, this will have been discussed and agreed at the Multi-Disciplinary Team meeting and will be discussed with you in detail about what this means. If you are not offered this pathway, it may be because this is a pathway that is being developed within specialities and it may not be available within the team who are treating you at this time.

When a person completes their primary treatment and goes on to a PSFU pathway, they will be offered:

  • Information about signs and symptoms to look out for, which could suggest their cancer has recurred or progressed, or which may be due to the side-effects of treatment.
  • Rapid access back 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.

Please note that if you put on to this pathway and do not wish to be, speak to your clinical team who can address your concerns and take appropriate action based on that discussion. It is also important to note that by going on to this pathway, you are not discharged from the care of your clinical team; this pathway is a self-management pathway but with rapid access back into the team if needed.

If the clinical team decide to put you on to this pathway, they will monitor your follow up scans and tests closely and if they are concerned about the results or if you are not managing to self-manage the care independently, it may be they decide to alter how your follow up care is managed but this will be discussed with you by a member of the clinical team.

If you have any questions about this pathway, please do not hesitate to contact your clinical team or the Personalised Care Team who will be happy to answer any questions you may have.

Background to the Cancer Care Review (CCR)

Patient cancer care contact and follow up is currently available in all GP practices. Cancer Care Reviews (CCR’s) are part of that process and so these are currently available in all GP practices.

What is a Cancer Care Review (CCR) in Primary Care?

A Cancer Care Review (CCR) is a conversation between a patient and a healthcare professional about their cancer journey. It is essential to personalised care and helps patients to:

  • talk about their cancer experience and concerns,
  • understand what support is available in their community; and
  • receive the information they need to begin supported self-management.

The Cancer Care Review is part of the Quality on Outcomes Framework (QOF).

What is the Quality on Outcomes Framework (QOF)?

The Quality and Outcomes Framework (QOF) is a voluntary annual reward and incentive programme for all GP practices in England, detailing practice achievement results. It is not about performance management but resourcing and rewarding good practice.

For more information, please visit the NHS England website: Quality and Outcomes Framework

Quality on Outcomes Framework (QOF) changes during 2021/22

In recognising the important role that primary care plays to support people after a cancer diagnosis, changes were made to the 2021/22 Quality and Outcomes Framework (QOF) cancer requirements.

The changes focus on key times of need when patients may feel vulnerable. These include:

  • at the time of a patient’s diagnosis (within 3 months)
  • after a patient has received acute treatment (within 12 months)

The Macmillan Community Care Project: Cancer Care Reviews in Shropshire, Telford & Wrekin

A project, funded by Macmillan, that ran over two years had a focus of:

  • Increasing the number of Cancer Care Reviews completed within 12 months of diagnosis,
  • Improving the quality of Cancer Care Reviews completed within 12 months of diagnosis,
  • Improving the awareness of the Cancer Care Review process to patients living with and beyond cancer; and
  • Improving patient’s satisfaction with their Cancer Care Reviews within 12 months of diagnosis.

To do this, the project funded non-clinical healthcare professionals to support people in the community with non-clinical concerns including:

  • Help with their non-medical concerns,
  • Looking at the patient and carers’ information needs,
  • Helping the patient understand what support is available locally in and around their community,
  • Receiving the information they need to begin supported self-management; and
  • Receiving details and signposting for support to a variety of organisations and services.

Following the pilot project, it was highlighted within the Primary Care Networks, the importance of supporting the person holistically. Steps have been made within PCNs to introduce Cancer Care Coordinators to support the patients and their colleagues with non-clinical worries or concerns. They work closely with multiple teams including the Cancer Care Navigators within the Trust and the Social Prescribing Teams based in the community.

Contact Us

Personalised Care Lead and Cancer Improvement Facilitator: Leah Morgan

Personalised Care Navigator: Katey Evans

Telephone: 01743 492424

Email: sath.lwbc@nhs.net

Follow us on social media 

Facebook: Living With and Beyond Cancer Programme or search ‘living with and beyond cancer programme’

Instagram: LivingWith&BeyondCancerProgram or search ‘livingwith.beyondcancerprogramme’

X/Twitter: SaTHLWBC or search ‘@SaTHLWBC’