Support interventions

The NHS Long Term Plan for Cancer states that “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.”

Thames Valley Cancer Alliance and voluntary groups are supporting the implementation of the Recovery Package across primary and secondary care and other voluntary sectors to meet the needs health and wellbeing needs of patients personalised care.

The key features of the package are:

  • a holistic needs assessment and a written individualised care and support plan at key points across the pathway. This should be agreed with and owned by the patient as well as shared with the local healthcare professionals designated in the plan. It should take a whole system approach to care planning taking in to account social circumstances, mental health needs, and any co-morbidities.
  • a treatment summary completed at the end of every phase of acute treatment, sent to the patient and their GP – which provides information about side effects and/or consequences of treatment, signs and symptoms of a recurrence and READ codes for the diagnosis and treatment so that the GP can update their patient database.
  • a cancer care review to discuss ongoing needs and completed by the patient’s GP or practice nurse within six months of a cancer diagnosis and covers post-treatment support, financial impact of cancer and information needs to enable self-management.
  • access to a patient education and support event, such as a health and wellbeing clinic, to prepare the person for the transition to supported self-management, including advice on healthy lifestyle and physical activity.

Nikki Hayward, Personalised Care Nurse from Buckinghamshire Healthcare NHS Trust explains how a Holistic Needs Assessment can help identify areas of your life with which you can access some additional support.

Support for delivering personalised care and support planning

There are many resources available for Healthcare Professionals to support them in the delivery of personalised care and support planning. We recommend colleagues sign up to the Macmillan Learning Hub and the Personalised Care Institute for the latest, up to date, training resources.

The Personalised Care: Practical Implementation Guide for Cancer Care Reviews has been published by Macmillan to support practices with the knowledge, tips and tools to set up meaningful cancer care reviews.

Personalised Care
       SNOMED Codes for Personalised Care