1. Transforming Care After Treatment (TCAT)
Driving Momentum:
Transforming Care After Treatment (TCAT)
Alison Watt, TCAT Project Lead (Fife)
Debbie Provan, Regional TCAT Lead (WoSCAN)
Gordon McLean, Programme Manager (Macmillan)

2. WiFi name: WifiLoveMCR Password: internet Join the conversation on Twitter using #DrivingChange

3. Transforming Care After Treatment
5 year programme
Scotland wide agenda to transform care and an exemplar model of integration
£5m programme fund
Supported by investment from Macmillan
Delivered in partnership
NHS Scot, Scot Govt, Cancer Networks, Social Work Scotland, People affected by Cancer, Cancer Coalition
Shared model of development
Design, test, evaluate and roll out new models of care

4. The overall aim of TCAT is to ensure that people affected by cancer in Scotland, are prepared and supported to live with the consequences of the diagnosis and its treatment.

5. Scottish Cancer Taskforce
To provide national leadership in the shaping and delivery of the partnership between Macmillan Cancer Support and the Scottish Government to transform cancer care after treatment.
TCAT Programme Board
Evaluation Advisory Group
Edinburgh Napier University
Supporting delivery across three networks providing a mechanism for Programme Manager and Network Project Managers to discuss delivery
To innovate and strengthen the approaches used to involve patients, carers and the public in the development of the cancer TCAT programme and hold the Programme Board to account for delivering improvements in patient experience.
Operation Support Group
Patient Experience Board
WOSCAN Project Group
11 Projects
NOSCAN Project Group
4 Projects
SCAN
Project Group
9 Projects + 1 National
Definition, delivery and evaluation of test / evaluation pilots
Supported by appropriate Project Governance Framework incorporating Network Leads , Managers, Macmillan Development Managers and appointed Project Managers

6. Assessment & Care Planning
New models of follow up based on individual need
Holistic Needs Assessment
Risk Stratification
Explicit preparation for care post treatment
Access to information and support
Assessment & Care Planning
End of Treatment Summaries / Cancer Care Reviews
Enablement Support / Health & Wellbeing Clinics
Transitions
Community based emotional/practical support
Work & Finance / Nutrition / Physical Activity
Support to self manage / Managing late effects
Rehabilitation
Alignment with broader Government agenda
Choice / dying at home
End of Life

7. Phase 1 Projects My Cancer Portal
Skin F/Up & TS
Prostate HNA &TS
Lung Palliative Care
Most Cancers Recovery Clinic
Breast HNA
H&N, Prostate & Colorectal HNA & H&WB
All Cancers HNA, TS & H&WB
Breast & Colorectal
TS, HNA, H&WB
Lung – PROM, F/UP H&WB

8. Top 10 Concerns Within Secondary Care Setting

9. Phase 2 Projects National TYA – TS & HNA All Cancers – Looking Forward
All Cancers Building Connections
Supported Self Management
National TYA – TS & HNA
Living Well After Treatment
PC – HNA & Self Management
Community Outreach
Service Co-ordination
CoT
All Cancers Individual Budgets
All Cancers CCR
Self Management Support
Employability Support
All Cancers – Reablement
Cognitive Rehab

10. Phase 3 Focus on spread and embedding learning from 1st two phases
Distribution of funds through shared decision making process with key stakeholders
Driven by Regional Cancer Networks

11. Cancer Experience Panel
Represent and empower service users to take a role in strategic decision making and care planning
Support local service user reference groups and provide representation at regional level
Promote the value of service user involvement at every level
Equal partner in allocation of Phase 2 funds and key stakeholder in Phase 3 process

12. Sustainability Challenges Approach Financial constraints
Spread to areas out with TCAT
Approach
Learn and share events: national, regional, local, and topic specific – cognitive rehabilitation, treatment summary, HNA
Links to, and involvement of, Managed Clinical Networks
Wider partnership working
Demonstrating efficiency – outcomes including economic impact (9 projects)
Service user experience
Communication strategy including evaluation outcomes via regional and national channels, infographics and media work

14. TCAT Case Study from Phase 2 RR and her son JR
Referred to the TCAT service from the Social Work Contact Centre
Diagnosed with breast cancer but had a previous diagnosis over 10 years ago
Lives centrally in a large town with 19 year old son (JR)
Experiencing physical difficulties due to side effects of cancer treatment
Feeling unsupported and had difficulty accessing local support services
Feeling concerned about her son in his caring role as he was also studying at college
Holistic Need Assessment (HNA) completed

15. JR son of RR 19 years old. Living at home with his mum
Sister does not live locally but supports her brother on the phone i.e. texts
Carer for his mum, i.e. taking on household tasks
Studying full time at college
Did not know where to access support but knew support was available
Carer Self-Assessment completed

16. The Cancer Journey – Discussion
Individually, using the HNA - tick the boxes which you feel are RR’s concerns. As a group discuss the highlighted concerns from your table’s perspective and what your role is in RR’s cancer journey. Use the Cog diagram plot RR’s cancer journey thinking about the person, working together, communication and resources
The following questions may assist you;
What is your role in RR’s pathway?
Who should you communicate with and how?
Who do you expect to communicate with you and how?
What is the driver for the Cogs

17. Cog Diagram Outlining RR’s Pathway
Community Palliative Care
CNS GP
College OT JR
RR,
LAC &
HNA
Teenage & Young Person Psychologist
Community Befriender
Community Listening Service
Hobbies & Outings

18. Alison.Watt@Fife.gcsx.gov.uk Debbie.Provan@ggc.scot.nhs.uk