Sarita Yaganti
Project Lead
Service Improvement
Cancer Commissioning Team
West and South London
Cancer Commissioning Team: West & South
London
• 20 CCGs
• 17 Trusts
• 5 million people (ONS)
• 3 ex-Cancer Networks
• 2 CCT patient groups
• 2 CSUs
• 1 Integrated Cancer
System (the London
Cancer Alliance)
The London cancer landscape
 Reconfiguration of Cancer Networks and Pan London
Teams – 5 became 3
and soon 3 will become 1
 2 Integrated Cancer Systems (provider)
- London Cancer (North and North Central London)
- London Cancer Alliance (North West and South London)
- pathway groups (one for each tumour site)
 5 year cancer strategy for London being developed
 Pan London Living with and Beyond Cancer work stream in
place
What we know about current
follow-up
 Variation:
 in follow up protocols across the geography
 in the content of the follow-up consultation
 information give to patient
 patients expectation and understanding of treatment
 Willingness of patients to have follow up but want a “cancer
specialist” in primary care
 CCGs Care Closer to Home agenda highlights the potential for
delivering primary care-led and delivered follow-up systems
Our ambition for follow-up
 No “one-size fits all” follow-up pathway
 Ensure patient choice can be exercised and patient experience is
enhanced
 Through training and education, we can assist primary and community
teams to position themselves to provide care closer to home
 Quality standards for follow up pathways are to be reflected in future
commissioning arrangements
 To continue to work collaboratively with patients, health professionals,
cancer charities to benefit the ongoing development and improvement
in follow-up cancer care
Our aim for this project
...is to examine the evidence to discover and
agree the best practice follow up of
suitable men living with and beyond
prostate cancer in primary care and to
recommend commissioning options for
service delivery models.
Project objectives – the why
 To provide patients living with prostate cancer a safe,
comprehensive follow-up service delivered by primary care
 Ensure care is tailored to patient's holistic needs (namely
psycho/sexual/social) and access to support services is available
and equitable
Employ 2 Band 8a Nurses to:
 To identify what is needed to provide an appropriately skilled
primary care workforce to deliver this model
 To enable practice nurses to support patients living with and
beyond a prostate cancer
 Testing and evaluating a model of care
The Process – the how
Supported by the CCT, two Band 8a nurses to take the project
forward (recruitment in process)
Mapping / Data
- Patient and
professional interviews
GP v nurse
Evaluate current
patient information
(including verbal
discussion on side
effects)
Training and
Developing primary
care
Set up transfer of
patients and
information
Pilot the identified
best practice model in
Croydon CCG
Revaluate patient and
professional
experience
Recommend best
practice model for CCG
commissioning
- what, where, how,
why, who, when?
Financial modelling:
primary v secondary
consultant v nurse
Key deliverables – the what
 Clearly defined, costed follow up model for the target
patient group
 Establish data metrics for auditing
 Clarify the infrastructure required in primary care to
deliver the pathway
 Set up/improve rapid access referral back into
secondary care
 To provide a locally accessible service for patients and
ensure choice of follow up is given as standard
Challenges
 Recruitment – second time round 
 New world of CSUs = exciting, hair raising twists and turns
at each corner!
 Things that we took for granted i.e. employing clinical staff
for clinical roles
 Data, data, data :
 Identifying data sources e.g. primary care v secondary care
data
 Coding – what coding?
 Being very clear on what data you want need.
The future
 Developing ways of providing patient access to specialist clinical
support within primary care
 Established “key worker” policies for follow-up patients
 Clear understanding of costs of different follow up pathways
 Peripatetic workforce – promoting shared resources between practices
 Continue to evaluate services by using consulting with those that are a
part of the service – patients/providers/professions
 Work with patients on what will enable them to be open and honest
about how the emotive side to cancer effects them so that holistic
needs can be met
 Learn from each other.....so.....
Let’s talk...
Sarita Yaganti: Project Lead, CCT North West & South
London
sarita.yaganti@nwlcsu.nhs.uk
Barbara Gallagher: User Involvement Lead, CCT West &
South London
b.gallagher@nhs.net
proudly supports