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National Cancer Survivorship Initiative

Stratified Pathways of Care

Pathways of care

The transformed pathway of care for cancer survivors is based on a model of care for people with long term conditions.  A stratification process will help to identify which care pathway is most suitable for each patient, based on the level of care needed for the disease, the treatment and the patient’s ability to manage, and therefore what level of professional involvement will be required.

The NCSI developed a series of principles for supporting people living with and beyond cancer.  Following cancer treatment patients should be offered:

  • A holistic needs assessment which builds on previous assessments and focuses on a patient’s medical, psychological, social, spiritual, financial and informational needs following treatment.  Through this holistic needs assessment the clinician and patient develop a care plan in partnership.
  • The Treatment Summary is completed by the hospital with copies going to the patient and their GP.
  • Where patients are assessed as being able to self manage, support should be offered in terms of access to an appropriate education event, self management course or Health and Wellbeing Clinic for information and support including lifestyle advice and interventions, physical activity programmes and vocational rehabilitation support.
  • New pathways of care which are underpinned by care co-ordination systems,  robust remote surveillance, so that patients will automatically be recalled if there is a problem identified in their tests, and rapid access to appropriate services if the patient has a concern or there is suspicion of further disease.
  • Planned and informed transition from paediatric to young person and adult services, where appropriate, and support to continue in education or begin a career.

The NCSI tested stratified pathways of care for those living with breast, colorectal and prostate cancer in 8 prototype sites across England from 2012.  In March 2013 NHS improvement published Innovation to implementation: Stratified pathways of care for people living with or beyond cancer- A “how to guide”,  as a guide to support implementation in practice.

The NCSI adult survivorship pathway work has also been approved by NICE as a proven case study and published as a QIPP case study on the NICE website.

The work, submitted by NHS Improving Quality, gives a clear and succinct account of the effectiveness of the new pathways against the QIPP criteria of savings, quality, evidence and implementability.   The case study also shows what elements need to be in place for stratified pathways to work effectively, and the likely resources that will be released.

Evaluation of adult cancer aftercare

A survey of NHS Improvement prototype sites was carried out by IPSOS-MORI in 2011. The aim of the survey was to provide a baseline for the 11 tumour projects within the seven Test Communities, who are testing a new model of care which includes stratified care pathways in Adult Cancer Survivorship services. This project is part of the National Cancer Survivorship Initiative.

This generic interactive pathway is designed for health care professionals and demonstrates examples of resources for care and support from previous and current testing work that are useful when developing a stratified care pathway.

Last updated on February 5, 2014