Personalised Cancer Care
Personalised cancer care is a partnership between a person and their cancer team, where support is provided at the right time and in the right place, prioritising what matters most to the individual. This collaborative approach ensures care meets people’s specific needs, achieves the best possible outcomes for them and supports individuals with cancer to be active and live well as fully as possible.
Effective personalised cancer care provides people with information about living a healthy lifestyle and support to self-manage their condition. It includes help on the physical and emotional effects of cancer and its treatment, as well as financial, practical and social support.
Ultimately, it aims to contribute to people having a positive experience of their care and a good quality of life during and after cancer treatment.
Our Personalised Cancer Care programme
In North Central London, our vision is for all people living with and affected by cancer in our area to have the best possible experience through high-quality personalised care and support. Our Personalised Cancer Care Strategy is an ambitious, integrated view of how care should be provided.
Aligning with national and local priorities, the Alliance works with partners to deliver activities such as holistic needs assessments, treatment summaries and cancer care reviews, as well as providing health and wellbeing resources, emotional, financial and return to work support.
The programme also aims to enable all individuals to have access to rehabilitation and psychosocial support from the point of diagnosis.
This means:
- People and their treatment and care experiences, and ongoing quality of life are at the heart of how we work.
- People with cancer receive care and support to live as well as possible during and after cancer treatment.
- Care and support is tailored to each person’s unique needs, circumstances and preferences – because people are affected by cancer differently.
- People living with and affected by cancer are partners in their own care and support and make decisions on what matters to them and what they really need.
- People living with and affected by cancer experience coordinated and smooth transitions between health and care providers.
Our programme aims are:
- To improve access to personalised care after diagnosis and at key points on the pathway.
- To personalise every follow-up pathway, based on an individual’s personal needs including, where appropriate, patient-initiated follow-up.
- For individuals to access timely, appropriate psychological support and pre/rehabilitation at any point.
- To record and track personalised care activity consistently through clinical information systems to show monitoring arrangements across North Central London.
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Our work in key areas
We are supporting the implementation of:
- Holistic needs assessments: Conversations between a person with cancer and a healthcare professional in which needs and concerns can be identified and addressed at the earliest opportunity.
- Treatment summaries: Completed at the end of primary treatment, including information on possible treatment toxicities and/or consequences of treatment, signs and symptoms that should be investigated , and an ongoing management plan.
- Cancer care reviews: Holistic conversations with patients in primary care, usually within 6-12 months of diagnosis.
- Health and wellbeing support and information: Including emotional support, coping with side effects, physical wellbeing, financial advice, getting back to work and making healthy lifestyle choices. Visit our webpage for patient information.
Clinical teams and the person with cancer make a collective decision about the best form of aftercare based on the individual’s clinical and personal needs. NCLCA is working to embed PFU pathways for people with breast, colorectal, prostate and endometrial cancers.
Individuals are directed to either:
- Professional-led follow-up pathway: Face-to-face, video, phone or email contact with their clinical team as part of continuing follow-up. Appointments may be led by doctors, nurses or specialist allied health professionals. Follow-ups may be delivered by the specialist team or the primary care team.
OR - Patient initiated follow-up (PIFU) pathway: Individuals receive knowledge and skills to self-manage their condition – information about symptoms, who to contact if they notice any, dates of future scheduled tests and how to contact specialist teams with concerns.
PIFU pathways also include the following key features:
- Effective needs assessment at the end of treatment
- Removal of routine follow-up appointments from the pathway
- Good communication between specialist, community and primary care teams.
- A robust remote monitoring system to manage ongoing surveillance tests and ensure no-one is missed for follow-up tests
- Rapid re-entry into the specialist cancer service if required, without having to go through their GP
We are working with commissioners and providers to ensure emotional support is available across cancer pathways through an integrated psychosocial support model.
This includes ensuring psycho-oncology is represented in multidisciplinary teams, sufficient NHS talking therapies capacity and clear referral pathways for specialist care.
Enhanced support requires trained staff and accessible resources. Universal support emphasises compassionate communication training for all staff and access to peer and community support.
Your Cancer Pathway Support Guide was developed with patients, carers, Healthwatch Barnet and Macmillan Cancer Support. It is a practical tool available digitally and in print.
It covers key information for people referred on a suspected cancer pathway or diagnosed with cancer, supporting patients and carers with guidance, questions to ask during appointments with their cancer team and signposting to support services.
PREPARE
This Royal Free London pilot delivers in-person group health and wellbeing sessions to support individuals to prepare for cancer treatment. Topics covered include eating well, keeping physically active, emotional wellbeing, and identifying and managing treatment side effects and late effects.
Future plans include sessions tailored to tumour type and expanding access to additional hospital sites in North Central London and into non-English speaking communities.
Prostate Buddy Scheme
A joint initiative between UCLH and NCLCA developed to address reasons for inequality in prostate cancer for Black men. Non-clinical ‘buddies’ of Black African or Afro-Caribbean heritage provide informal, culturally sensitive support and guidance to patients.