Living with and beyond Cancer Diagnosis Treatment Recurrence Curative intent Survival Living with Cancer Palliative/ EOL care Introduce ourselves (Pam and Jill) As cancer incidence is increasing, so too is the number of people living with cancer and this is expected to increase to 3.4 million nationally by 2030. Breast, lung, prostate and colorectal cancers account for half of all diagnosis and 40% of all cancers can be attributed to lifestyle factors. As part of my role, I will be looking at the implementation of national optimal cancer pathways (from referral to diagnosis to treatment) as well as how we ensure that we look at pathways not only from referral to treatment , but also into survivorship or end of life. Health and care working together in South Yorkshire and Bassetlaw

Cancer Recovery Package Whole person, whole pathway approach Improve quality of life for people living with and beyond cancer https://www.youtube.com/watch?v=eapd1JEmCjI PAM – video to 4 mins 28 seconds Cancer Task force recommendations are a set of interventions designed to deliver a person centred approach to care for people affected by cancer. This means the implementation of the Recovery package which is a person centred conversation with the output being a meaningful shared careplan. Effective assessment and care planning can lead to early interventions, diagnosis of consequences of treatment, improved communication and better equity of care. The Recovery Package is a set of essential interventions designed to deliver a person centred approach to care for people affected by cancer. This includes: • Holistic Needs Assessment (HNA) and care planning • Treatment Summary (TS) • Health and wellbeing events • Cancer care review (CCR) These elements form part of an overall support and self-management package for people affected by cancer – physical activity as part of a healthy lifestyle, managing consequences of treatment, and information, financial and work support. Health and care working together in South Yorkshire and Bassetlaw

Risk stratified pathways Working within the SYBND cancer alliance to agree risk stratified pathways for Prostate, colorectal, breast Stratified follow-up pathways comprise needs assessment, support for patients to self-manage, remote monitoring and re-entry pathways. This can offer a more effective approach to after-care than traditional medical models of follow-up. More tailored care in this phase has the potential to reduce costs through reducing recurrences, better managing side-effects, improving patient satisfaction and supporting people to live well. In general, individuals deemed at low risk of recurrence and late effects (physical and psychosocial), should be encouraged towards supported self-management, those at medium risk may receive planned coordinated care and those at high risk should receive complex care from specialist services. A system must be developed for rapid re-entry to the specialist cancer service as required. A model of follow-up in which the clinical team and the person living with cancer make a decision about the best form of aftercare based on the individual’s clinical and personalised needs. Individuals enter either a personalised clinical follow-up pathway or a supported self-management pathway. The stratified follow-up pathway extends 5 years from the point of diagnosis. Health and care working together in South Yorkshire and Bassetlaw

Any questions? End of treatment is almost never the full story….. Patient GP Cancer Services What’s the matter with you? What matters to you? (Health Foundation) We have a duty of care to the person as a whole and not just their cancer (Doyle & Henry 2014) Thank you for listening. Any questions? Ask for GPs to work with us to develop treatment summaries and CCRs – put this onto your evaluation form if interested Any of the GPs can contact Lead Cancer nurse Sheree Hall for more detail or if you have any questions on HNA https://www.england.nhs.uk/wp-content/uploads/2018/07/national-living-with-and-beyond-cancer-baseline-activity.pdf https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/Stratified-Pathways-of-Care.pdf Health and care working together in South Yorkshire and Bassetlaw