Follow Up Models Pilot Project
Service Redesign of Adult Cancer Aftercare Services at University Hospital Southampton NHS Foundation Trust for breast, colorectal and testis patients: Supported Self Managed Follow –Up.
The aim of this project was to redesign cancer follow up services to move from routine face to face outpatient episodes, to a tailored approach based on the preparation of patients to self manage their follow up and trigger their return for advice and guidance if they deemed it necessary. Published evidence supports the adoption of this model.
Two years of pathway design (January 2010 – December 2011) supported by two project support officers and a Clinical Lead achieved the implementation of new supported self managed service pathways in January 2012. The following key elements had been designed, developed, tested, and revised, and were in place for the sustainable provision of self managed follow – up, and include:
- Remote monitoring of cancer surveillance tests: two models were developed, one based within the Trust cancer data system, and the second a pilot of a web based patient portal system(pilot complete November 2013). Such systems need to be robust and trusted by clinicians, and should include accurate surveillance templates for each tumour group; alerts to the need for testing and clinician review of results; import of diagnostic and treatment records; generate treatment summaries; and processes for regular governance audit reports.
- Patient preparation: All patients are prepared from diagnosis and in the final clinic consultation, and are taken through tailored personalised information. Colorectal and testis patients attend a specifically designed four hour self management workshop which supports their physical and psychological health, confidence with self monitoring and self confidence to look after themselves.
- Clear contact point for issues of concern through nurse specialists and coordinator support workers.
- Rapid and easy access back to the appropriate person/service without recourse to their GP.
- Agreement with Clinical Commissioning Groups, and a local tariff which ensures income for the Trust for aftercare which does not include a face to face outpatient attendance.
Over the year of implementation, clinician outpatient practice has been adapting and changing to ensure that this form of follow up is safe and effective for their patients. The spread of the innovation in the Trust is progressing for gynaecological, lymphoma, and prostate cancer patients. The first year delivery of the self management workshops has been evaluated and reports will be available in the future.
A robust service evaluation is ongoing which includes a longitudinal survey of two cohorts of patients – a pre-change group of patients who are receiving usual outpatient follow up,(data collection March 2011-Dec 2012) and a post change cohort of patients receiving self managed follow up(data collection January 2012 – June 2013). Both groups are followed up for one year and complete a comprehensive questionnaire at the end of treatment, and at four, eight, and 12 months later. The methods also include in-depth interviews with a subgroup of patients. The process of change is also being evaluated using qualitative methods. Data collection will be completed in September 2013, and analysis and reporting in 2013/2014.
For further information about the service redesign or the service evaluation please contact Lynn Batehup Lbatehup@Macmillan.org.uk
Last updated on January 28, 2013
- Development and Qualitative Evaluation of a Self Management Workshop for Testicular Cancer Survivor-Initiated Follow – Up [PDF, 602 KB]
- Redesign and Evaluation of Adult Cancer Aftercare Services [PDF, 213KB]
- Towards a personalised approach to aftercare: a review of cancer Follow-up in the UK [PDF, 152KB]