1. Primary Care Stratified Follow-up of Stable Prostate Cancer Patients
Dr Imogen Staveley: Cancer Clinical Lead
and
Astrid Holness
Cancer Commissioner

2. Primary Care Stratified Follow-up of Stable Prostate Cancer Patients
This is an NCL wide service led by Barnet CCG for Stable Prostate Cancer patients
Go live date aim is 1st June 2017

3. What are the objectives of the Prostate Cancer Service?
To improve quality of care through robust safety-netting and rapid re-referral to secondary care for patients identified with progressive disease
To improve patients’ experience through cancer care review, signposting to services, care closer to home
To improve secondary care capacity by releasing time for consultants to manage more complex patients

4. Who is eligible for this service?
Stable prostate cancer patients (read codes and detail in the specification)

5. Who is not eligible for this service?
Patients on active surveillance
Patients being treated with brachytherapy
Patients at high risk that had radical radiotherapy or surgery
Patients being treated with focal therapy
Individuals participating in clinical trials follow-up

6. How will this service work? I
Using the templates and resources provided General Practice are to:-
Develop and maintain a prostate cancer follow-up register that includes an active recall system of all prostate cancer patients with read code in appendix 5 and 7 of the service specification.
Provide all newly transferred patients with a 30 minute holistic ‘welcome appointment’ within four weeks of notification transfer from secondary care.
Signpost patients to resources for promoting self-management of symptoms such as fatigue and incontinence as well as signposting to appropriate services.

7. How will this service work? II
Ensure that PSA levels are checked against patient specific “normal ranges”/parameters (outlined in the treatment summary) twice per year. Provide patients with their PSA tests results
Follow up any patients that fail to make and attend the review consultation. Document in the patients’ record if they decline a follow-up and re-invite the patient at least annually.
Ensure that patients are referred back into secondary care urgently and ensure they are seen within 14 days (use a special form and then send electronically using 2ww address or e-referral)
Identify a named clinical lead (GP or Nurse) to attend arranged training to complete a minimum 30 minute training session accredited by BMJ Learning and disseminate training material to other staff within the practice.

8. How would the contract work?
GPs would be paid annually to for maintaining the register, providing a robust recall service, conducting an annual cancer and doing and acting on two PSA tests.
Contract will be monitored on an annual basis
GPs to participate in the annual evaluation of the service via an online survey

9. Resources
Information and leaflets from the prostate cancer UK will be disseminated to all GP Practices
‘How to implement the service video’ will be posted on the GP website for all practices
Access to the BMJ online modules made accessible via a link on the GP website

10. Register your interest
If you are interested in this service please register your interest at

11. Questions
for clinical questions and for commissioning questions.

12. How will this service work?
Secondary Care
Identify and transfer stable prostate cancer patients into Primary care that are currently being followed up within the Urology department at UCLH and Royal Free. The transfer of the patients will take place pending agreement with the consultants
Will inform the GPs when the process has been completed
Send GPs a discharge letter with the patients Holistic Needs Assessment and Treatment Summary