The South East London Cancer Alliance cancer care group developed the following statement:
"Our patients are at the centre of the care that we give. We aspire to work
in partnership with people living with cancer to assess and meet their needs throughout their entire cancer experience, personalised to what matters most to them.
We are committed to ensuring our patients and their families know of all physical, emotional and practical support available to them including help and services near to where they live, regardless of where or when they received their cancer treatment.
We strive to provide accessible, equitable, resilient and sustainable cancer supportive care for all in SE London."
This section outlines resources and tools for professionals to deliver personalised care to patients.
Personalised care means giving patients more choice and control over their care, based on what matters most to them as individuals.
Personalised Cancer Care is a partnership between people with cancer and their professional team, providing access to care and support that meets their individual needs from the moment they receive their cancer diagnosis so that they can live as full, healthy and active a life as possible.
Please find below the up to 2021-2024 SELCA personalised cancer care strategy.This strategy is delivered by the South East London Cancer Alliance personalised cancer care group.
With partners, we have produced a patient information leaflet outlining the personalised care they should expect when undergoing cancer treatment.
The specialist team at Guy's Cancer Centre have created a Cancer Related Fatigue education module to help patients, their friends and family to manage and reduce fatigue including some practical tips, guidance, and exercises.
Please signpost this resource to your patients.
Proactive management of lymphoedema is important. Please refer patients to the following resources while they await their appointment.
- UK NHS Lymphoedema Network Wales specialists and patients have created a collection of 13 short films to help you understand and manage your lymphoedema.
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Cancer Wellbeing London have produced a series of videos demonstrating exercises for patients with lymphoedema.
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LymphConnect is an online platform to help patients manage their lymphoedema and link with other patients for support.
- The Lymphoedema Support Network (LSN) https://www.lymphoedema.org/ provides comprehensive information for patients, offering guidance on treatment, self-management, common questions, and support groups.
If you would like to learn more about lymphoedema, please see Guy's Cancer Academy Lymphoedema webinar here or visit North East London Cancer Alliance page for a comprehensive list of information.
SEL Lymphoedema Services by borough are listed below:
Bexley:
Accepts cancer related and non cancer related conditions.
T: 02033197623
Bromley:
Accepts cancer related and non cancer related conditions.
T: 03003305777
Greenwich:
Accepts cancer related and non cancer related conditions.
E: oxl-tr.greenwichlymph@nhs.net
GSTT:
Accepts cancer related only, requiring cancer diagnosis with a GP in a Lambeth, Southwark or Lewisham and/or recieved all or part of their cancer care at GSTT.
E: gst-tr.lymphoedemagstt.nhs.net
Lewisham:
Accepts cancer related and non cancer related conditions.
What is social prescribing and when can it be useful?
People affected by cancer have wider issues than can be solved with clinical treatments alone. For example, we might see people who have been experiencing loneliness or facing practical financial worries.
Social prescribing is a really valuable way for primary care to:
• support people affected by cancer to manage their needs;
• bring benefits to their health;
• and, provide all of this in a way that is most appropriate for them.
The impact of life circumstances such as housing, employment, and environment on people's health and recovery from illness is well known. What is new, is that we now have models of care that can join up the different services to support people, enabling us to try and meet their non-clinical needs. Social prescribing is a central part of the drive towards personalised care, which aims to help professionals to consider all the factors affecting a person's health. This enables people to have more control over their own health and care, managing their needs in a way that suits them.
As this is a new service within the NHS, many practitioners will not yet be familiar with social prescribing services and their potential, and the sort of situations in which they can help. Therefore, this short resource from Guy's Cancer Academy provides a comprehensive but concise, overview of the what, why and how of social prescribing in your context.
People living with cancer have varied needs and cancer can affect all aspects of life, from relationships to work or finance. Cancer can have a huge emotional impact on the individual and those around them.
Social prescribing is now available in all areas of south east London enabling people to access help with facing difficulties close to home.
Contact details vary by area. In Bexley, Greenwich, Lambeth, and Lewisham referral can be made directly to the SP team. In other areas referrals must be done via GP services.
Bexley
Community Connect is the Bexley service in which Community Wellbeing Co-ordinators can help you to find support for issues outside of the usual care that your GP or nurse may be able to provide. Community Connect accept self referrals via e mail or phone, or can offer advice to professionals about local services which they may want to signpost patients to. Please visit the website here.
Greenwich
The Live Well Greenwich line is a free helpline staffed by local, trained health and wellbeing advisors for signposting and support to live well. Tel: 0800 470 4831. Monday–Thursday, 8.30am–7.30pm; Friday, 8.30am–5.30pm; Saturday, 9am–12 noon. A message can be left outside of these hours. For more information about services to signpost to please visit here.
Lambeth
If you are a professional, please visit AgeUK Lambeth or email info@ageuklambeth.org for advice before making a referral that requires an immediate or urgent response. If someone needs urgent support please advise them to make contact over the phone: 0333 360 3700, Monday–Friday, 9.30am–4.30pm (excluding bank holidays). If you are a patient, you can self refer to Connect Lambeth by calling 0333 360 3700 or to find out more, visit their website here.
Lewisham
Community Connections Lewisham is a Social Prescribing service, run by Age UK Lewisham and Southwark. To get in touch call 0330 058 3464, Monday to Friday, 9.30am-4pm (*except on Thursdays when we are open from 2-4pm only) for Lewisham residents, or people registered to a Lewisham GP, over the age of 18. If you are a patient you can self refer to Community Connections Lewisham by visiting their website here.
Bromley
Visit Bromley Well's website or Tel. 0808 278 7898, Monday–Saturday, 9am–5pm. You can find more information here.
Southwark
North: Quay Health Solutions, Monday–Friday, 9am-5pm, Contact qhs.socialprescribing@nhs.net or for more information, visit their website here.
South: Improving Health Limited, Monday–Friday, 9am-5pm, Contact ih.socialprescribers@nhs.net or for more information, visit their website here.
For patients moving towards survivorship guidelines and prioritising overall health, weight management is an important consideration. Encouraging a healthy weight and regular activity enhances strength, reduces fatigue, and helps lower risks of heart disease, strokes, type 2 diabetes, and certain cancers or cancer recurrence.
We have coproduced symptom help sheets for professionals with subject matter experts in SE London which can be found here and includes information on maintaining a healthy weight.
Cancer and treatments can lead to many side effects- fatigue, pain, poor sleep, low mood and weight changes. The good news that physical activity and exercise can help in all these areas! We have created tumour specific 'top tips' resource for professionals to use when giving advice and information to patients around physical activity, click here.
Each South East London borough has developed a useful infographic outlining the weight management services available. Click on the relevant borough to direct appropriate patients to the available resources.
Important Note: For patients currently undergoing active cancer treatment with specific nutritional needs, specialised dietary guidance is recommended. Please refer to your local nutrition and dietetic service.
Lambeth - The Healthy Living Team from Guy's and St Thomas' Trust offers two programmes:
Lambeth Healthy Weight for Lambeth residents or those registered with a Lambeth GP. it is a 12-week programme offering structured physical activity, nutritional education and behaviour change techniques in a group setting. This programme is for participatnts who are motivated to change their lifestyle and able to commit to regular attendance at the session.
Fits Me Well is specially tailored for those of Black-African and Black-Caribbean hertitage. This programme is all about helping you make choices that keep you healthy in the long run, all while enjoying your traditional food and customs. It runs for 12 weeks, so is packed with nutrition tips, behaviour change education and physical activity sessions.
To participate, patients GP can refer them or they can self-refer via this link
Bromley - coming soon!
Southwark - coming soon however in the meantime, you can visit this link for further information: Weight Loss Support for Adults in Southwark - Everyone Health Southwark
NHS England also offer a free weight management programme for NHS Staff, if you are a NHS employee and would like to know more please visit NHS England » Digital weight management programme for NHS staff
A holistic needs assessment covers a wide range of topics such as physical and emotional wellbeing, but also social elements such as family, finance and work.
It helps patients identify and prioritise what matters most to them and what they might need support with managing.
Once completed, this assessment will help to guide the conversation with your patient to enable a personalised care plan to be developed. This assessment should be offered around diagnosis and at other points on the cancer pathway.
Macmillan Cancer Support has created a guide for professionals providing holistic needs assessments, care and support planning.
This online learning package from Guy's Cancer Academy guides professionals on conducting care and supports planning consultations and completing care plans following the completion of holistic needs assessments (HNA) by people with cancer.
Information and support should be made available to patients during and beyond cancer treatment, including:
- emotional support;
- coping with side effects;
- physical wellbeing;
- advice about money;
- getting back to work;
- making healthy lifestyle choices.
A list of information resources and cancer information centres on sites in South East London is available here.
It is good practice and a Quality and Outcomes Framework (QoF) requirement for all patients to receive a phone call from their GP within the first 3 months of diagnosis.
The Cancer Care Review should be undertaken by a GP or Practice Nurse. It is a QoF requirement that this takes place within the first six-12 months following diagnosis––. The review should include:
- talking about the patient’s diagnosis and current needs and any worries they may have;
- any extra support they might need;
- a review of their medication;
- Outlining access to other services they may need, such as counsellors, rehabilitation specialists or social prescribers.
At the end of a period of treatment, a patient should receive a Treatment Summary from their secondary care provider. A Treatment Summary will include:
- The patient’s diagnosis;
- the treatment received;
- follow-up arrangements;
- possible long-term effects or complications;
- signs and symptoms to look out for;
- details of who to get in touch with if the patient needs support or are worried about anything.
A copy of this should be sent to the patient’s GP.
The NHS Long Term Plan for Cancer outlines that “after treatment, the person will move to a follow-up pathway that suits their needs, and ensures they can get rapid access to clinical support where they are worried that their cancer may have recurred.”
Personalised Stratified Follow-Up (PSFU) is a vital part of delivering world class cancer services to people while addressing the serious challenges of demand and capacity throughout cancer pathways.
The implementation of PSFU pathways provides better care and experience for patients. By reducing the amount of time that professionals spend seeing patients who are doing well after treatment, it also frees up professionals’ time to focus on other parts of cancer pathways, such as faster diagnosis and treatment, or those with complex post-treatment needs.
Having PSFU pathways means that when a person completes their primary treatment, they will be offered:
- information about signs and symptoms to look out for, which could suggest their cancer has recurred;
- rapid re-access to their cancer team, including telephone advice and support, if they are worried about any symptoms, including possible side-effects of treatment;
- regular surveillance scans or tests (depending on cancer type), with quicker and easier access to results so that any anxiety is kept to a minimum; and
- personalised care and support planning and support for self-management, to help them to improve their health and wellbeing in the long-term.
In South East London we are working with clinical teams across our three Trusts to roll out this method of follow up to breast, prostate, colorectal and endometrial patients from January 2023. Further pathways will then be guided on how to implement the follow up.
We have developed an information leaflet for primary care, which explains what patients can expect from a Personalised Stratified Follow Up (PSFU) and how primary care will be notified when a patient is placed on a PSFU pathway.
Quality of life can be about a patient’s emotions, social life, money, or physical wellbeing as understanding the impact cancer has on lives will help improve our quality of care. A patient will receive the Cancer Quality of Life Survey from NHS England either electronically or by post 18 months after their diagnosis. Find out ways you can help promote the survey to patients.
NHS England has produced a range of information on personalised care and improving quality of life outcomes.
Macmillan Cancer Support has created an introduction to personalised care as well as a toolkit to help primary care professionals with quality improvement initiatives.