The Recovery
Package
Hayley Williams
Macmillan Survivorship Programme Manager
South Yorkshire Bassetlaw and North Derbyshire
Dr Anthony Gore
GP Cancer Lead & Primary Care Champion
Sheffield CCG
Northern England SCN
November 10th 2014
Drivers for change
• Evidence base re value of traditional ‘medical
models’
• Patient
• Care Closer to Home agenda
• NCSI – March 2013
• CCG Revised Clinical Pathways
Remote monitoring
PROS
CONS
 Promotes individualised, risk
stratified approach to care
 Disease knowledge base in
primary care / interpretation of
results
 Care closer to home
 Less immediate access to
specialist team for advice
 Potential reduction in cost to
commissioners
 Viability of scheme for
individual practices
 Releases capacity in
secondary care
 ‘Loss of patient’ in system
Revised pathway
(NTCN 2011)
Old
 ‘One size fits all approach’
 5 years secondary care led
 CEA 3/12 (2yrs) 6/12 (3yrs)
 CT 9 and 24 months
 OPA 3/12 (2yrs) 6/12 (3 yrs.)
 Colonoscopy as per
need/protocol
New
 ‘Stratified pathway’ (not post
treatment)
 2 yrs. (colon) 3yrs (rectal)
secondary care
 Clinical components same
 OPA frequency reduced
 Transfer of care to PC under
LCS
Components of effective remote
monitoring
Managing patient expectations/ Information and knowledge
HNA and care planning
Educational support
Resources
Treatment summary
Transitional support
Health and well-being
Locally agreed protocols
and referral processes
LCS for primary care
Varied level scheme
Robust call/recall systems
+ link worker
Sheffield experience
 Patient expectations – revised
pathway as at 2011
 2 level LCS developed –
implementation = 12 months
 Locally relevant CEA protocol and
agreed referral mechanism
 The Recovery Package
 Resource tools
Education (PLI/ PN)
Enhanced Cancer Care review
template (colorectal specific content)
PRESS signposting tool
Overcoming Challenges
• Engagement
• Clarity
• Manage expectations
• Impact of patient – anxiety and uncertainty – can not
rely solely on them to make sure CEA protocol gets
followed
• Education key
Outcomes & Benefits of
Change
• Promote patient self-management
• Provide more effective yet efficient support to
cancer survivors
• Support which reduces an individual’s reliance
on traditional health care
• Transformational change
• Culture change
Outcomes & Benefits of
Change
• Effective engagement and collaboration
• Services ‘shaped’ by the patient voice
• Assurance of equitability
• Foster integrated approach
• Skill sharing/role development
• Use of data to drive commissioning
Sheffield Colorectal Cancer
Secondary care
- Follow up basic clinical pathway
5 yrly
Colonoscopy
Until
75 yrs.
Supported
Self
management
12/12
Colonoscopy
2/52 OPA +
CEA
Consultant
led
3/12 OPA +
CEA
Nurse
led
9/12 CT scan
OPA with
Result
+
CEA
24/12
CT scan
OPA with
Result
+
CEA
15/12
OPA +
CEA
36/12
OPA +
CEA
rectal
Primary Care
6/12 CEA
+
U+E pre
CT
12/12
CEA
18/12
CEA
21/12 CEA
+
U+E pre
CT
30/12
CEA
Shared care
Complex
Case
management
CEA
6/12
Until
5 years
CT
3m
OPA
+
CEA
9m
6m
OPA
12m
CEA CT result CEA
CEA
Cancer
Care
Review
CT
Colonoscopy
6/52
OPA
+
CEA
HNA
review
Colonoscopy
HNA + Care Plan
Health and well-being event
15m
OPA
+
CEA
18m
CEA
24m
21m
OPA
CEA CT result
CEA
Colonoscopy 5 yrly
HNA
colon
Risk Stratification
New Colorectal Pathway 2011
Treatment
Summary
Level 1
CEA 6 m
6m
OPA
for 1 yr.
CEA
HNA
rectal
Level 2
CEA 6 m
+
Review
Thank you