1. Living With & Beyond Cancer (Personalised Care): SWAG Colorectal CAG Update
5th June 2019
Catherine Neck, Macmillan Cancer Rehabilitation/ LWBC Lead
On behalf of SWAG Alliance

2. NHS Long Term Plan
By 2021, where appropriate every person diagnosed with cancer will have access to personalised care, including needs assessment, a care plan and health and wellbeing information and support.
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.
This stratified follow-up approach will be established in all trusts for breast cancer in 2019, for prostate and colorectal cancers in 2020

3. NHSE requirements for Personalised Care
From April 2020:
All breast, colorectal and prostate cancer patients from diagnosis (including secondary cancer) to have access to personalised support
Approximately two-thirds of patients who finish treatment for breast cancer to be on a supported self-management follow-up pathway and from diagnosis
All Alliance Trusts to have in place protocols for stratifying the follow up of prostate and colorectal patients and systems for remote monitoring for these patients and from diagnosis

4. SWAG LWBC Implementation 2019/20
Introduce remote monitoring systems for breast, prostate and colorectal
Support commissioners with evaluation to inform an options appraisal, which will support decision on the future delivery of personalised care and support across the Alliance
Continue collection of metrics that demonstrate patient experience and number of patients covered

5. Remote Monitoring & Ongoing Sustainability for LWBC
We will be funding the set-up costs of remote monitoring systems from Alliance funds in 2019/20 (perhaps My Medical Record)
We had thought that we might use some of our Alliance funding for 2019/20 to support CCGs to embed personalised care in recurrent funding – but both regional and National team were uncomfortable with this approach.
The risk to sustainability of the LWBC programme has been raised with national team and discussions are ongoing.

6. SWAG Colorectal Stratified Pathway
At end of treatment all patients to receive a CNS review which includes the following:
Holistic Needs Assessment and Care Plan
Booking onto a Health & Wellbeing Clinic. If patient has already attended an early H&WB clinic then to be given site specific advice about signs and symptoms of recurrence and possible late effects of treatment
Completion of Treatment Summary
Patients are then stratified into one of the following follow-up pathways. N.B. Patients should be reassessed and move freely between follow up pathways as their condition or needs change:
Supported self-management pathway with routine surveillance and open access
Shared Care
Complex case management
Discharged to GP care

7. Self-Management with Open Access:
Patients who are able to understand and engage with process
No active disease/ serious/ uncontrolled symptoms from treatment
Can be for all stages of colorectal cancer (primary)
All bloods, CTs, colonoscopies undertaken as per protocol

8. Shared Care: Patients requiring physical examination
Nurse-led clinic for those unable to engage with self-management pathway i.e. due to cognitive or psychological issues
Trials Patients (should  be on a pathway that meets  stipulations in trial protocol)

9. Complex Management via MDT:
Serious uncontrolled symptoms
Complex management or intense surveillance required i.e. following metastatic resections or T1 polypectomy’s
Palliative patients receiving treatment
Trials patients (or on shared care pathway)

10. Discharge to GP: Very frail patients
Patients for who no further active treatment would be offered
Not requiring further scans or blood tests

11. Self-management pathway process
Normal Results:
Results reviewed and patient informed via letter
Holistic Needs Assessment (paper copy and electronic link) sent with CT results at 1 and 2 years
Patient informed to make contact if help is needed and given reminder of next test date
Reminder of signs and symptoms given to patient

12. Self-management pathway process
Abnormal Results / Concerns / Symptoms:
Open access into system within 2 weeks
Further diagnostic tests as required
MDT review
OPA

13. Discussion/ Next Steps:
Need to understand current position of teams against this pathway
What steps are needed to move towards delivery of this pathway?