Transforming Care After Treatment (TCAT) Driving Momentum: Transforming Care After Treatment (TCAT) Alison Watt, TCAT Project Lead (Fife) Debbie Provan, Regional TCAT Lead (WoSCAN) Gordon McLean, Programme Manager (Macmillan)

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Transforming Care After Treatment 5 year programme Scotland wide agenda to transform care and an exemplar model of integration £5m programme fund Supported by investment from Macmillan Delivered in partnership NHS Scot, Scot Govt, Cancer Networks, Social Work Scotland, People affected by Cancer, Cancer Coalition Shared model of development Design, test, evaluate and roll out new models of care

The overall aim of TCAT is to ensure that people affected by cancer in Scotland, are prepared and supported to live with the consequences of the diagnosis and its treatment.

Scottish Cancer Taskforce To provide national leadership in the shaping and delivery of the partnership between Macmillan Cancer Support and the Scottish Government to transform cancer care after treatment. TCAT Programme Board Evaluation Advisory Group Edinburgh Napier University Supporting delivery across three networks providing a mechanism for Programme Manager and Network Project Managers to discuss delivery To innovate and strengthen the approaches used to involve patients, carers and the public in the development of the cancer TCAT programme and hold the Programme Board to account for delivering improvements in patient experience. Operation Support Group Patient Experience Board WOSCAN Project Group 11 Projects NOSCAN Project Group 4 Projects SCAN Project Group 9 Projects + 1 National Definition, delivery and evaluation of test / evaluation pilots Supported by appropriate Project Governance Framework incorporating Network Leads , Managers, Macmillan Development Managers and appointed Project Managers

Assessment & Care Planning New models of follow up based on individual need Holistic Needs Assessment Risk Stratification Explicit preparation for care post treatment Access to information and support Assessment & Care Planning End of Treatment Summaries / Cancer Care Reviews Enablement Support / Health & Wellbeing Clinics Transitions Community based emotional/practical support Work & Finance / Nutrition / Physical Activity Support to self manage / Managing late effects Rehabilitation Alignment with broader Government agenda Choice / dying at home End of Life

Phase 1 Projects My Cancer Portal Skin F/Up & TS Prostate HNA &TS Lung Palliative Care Most Cancers Recovery Clinic Breast HNA H&N, Prostate & Colorectal HNA & H&WB All Cancers HNA, TS & H&WB Breast & Colorectal TS, HNA, H&WB Lung – PROM, F/UP H&WB

Top 10 Concerns Within Secondary Care Setting

Phase 2 Projects National TYA – TS & HNA All Cancers – Looking Forward All Cancers Building Connections Supported Self Management National TYA – TS & HNA Living Well After Treatment PC – HNA & Self Management Community Outreach Service Co-ordination CoT All Cancers Individual Budgets All Cancers CCR Self Management Support Employability Support All Cancers – Reablement Cognitive Rehab

Phase 3 Focus on spread and embedding learning from 1st two phases Distribution of funds through shared decision making process with key stakeholders Driven by Regional Cancer Networks

Cancer Experience Panel Represent and empower service users to take a role in strategic decision making and care planning Support local service user reference groups and provide representation at regional level Promote the value of service user involvement at every level Equal partner in allocation of Phase 2 funds and key stakeholder in Phase 3 process

Sustainability Challenges Approach Financial constraints Spread to areas out with TCAT Approach Learn and share events: national, regional, local, and topic specific – cognitive rehabilitation, treatment summary, HNA Links to, and involvement of, Managed Clinical Networks Wider partnership working Demonstrating efficiency – outcomes including economic impact (9 projects) Service user experience Communication strategy including evaluation outcomes via regional and national channels, infographics and media work

TCAT Case Study from Phase 2 RR and her son JR Referred to the TCAT service from the Social Work Contact Centre Diagnosed with breast cancer but had a previous diagnosis over 10 years ago Lives centrally in a large town with 19 year old son (JR) Experiencing physical difficulties due to side effects of cancer treatment Feeling unsupported and had difficulty accessing local support services Feeling concerned about her son in his caring role as he was also studying at college Holistic Need Assessment (HNA) completed

JR son of RR 19 years old. Living at home with his mum Sister does not live locally but supports her brother on the phone i.e. texts Carer for his mum, i.e. taking on household tasks Studying full time at college Did not know where to access support but knew support was available Carer Self-Assessment completed

The Cancer Journey – Discussion Individually, using the HNA - tick the boxes which you feel are RR’s concerns. As a group discuss the highlighted concerns from your table’s perspective and what your role is in RR’s cancer journey. Use the Cog diagram plot RR’s cancer journey thinking about the person, working together, communication and resources The following questions may assist you; What is your role in RR’s pathway? Who should you communicate with and how? Who do you expect to communicate with you and how? What is the driver for the Cogs

Cog Diagram Outlining RR’s Pathway Community Palliative Care CNS GP College OT JR RR, LAC & HNA Teenage & Young Person Psychologist Community Befriender Community Listening Service Hobbies & Outings

Alison.Watt@Fife.gcsx.gov.uk Debbie.Provan@ggc.scot.nhs.uk GMcLean@Macmillan.org.uk http://www.gov.scot/Topics/Health/Services/Cancer/TCAT