The NHS Operational and Planning Guidance places requirements on Cancer Alliances to roll out personalised stratified follow up pathways for breast, colorectal, gynaecological and prostate pathways.
Patients will be stratified for follow up by their clinician and/or MDT team once active treatment has been completed based on clinical need. Follow up will take the form of professional led follow up (traditional consultant led clinics in an outpatient setting) for those with a higher risk of disease recurrence or self-management for lower risk patients who following treatment will no longer have routine consultant led appointments.
PSFU pathways will include the following key features
- Effective needs assessment at end of treatment that identifies and addresses any outstanding needs and ensures the patient has knowledge and confidence to manage their own care.
- A schedule of follow-up investigations for each pathway which is agreed by the Pathway Board for that tumour group
- Removal of routine follow up appointments from the pathway. The results of investigations will be reviewed by an appropriately qualified staff member and the patient is informed of the results (in line with clinical judgement and local protocols).
- Good communication between specialist, community, and primary care teams.
- A robust digital monitoring system to manage on-going surveillance tests and ensure no-one is missed for follow up tests.
- A system that allows rapid re-entry into the specialist cancer service if required. This reassures individuals that they can access appropriate, named support quickly should they need it without having to go via their GP.
As each PSFU pathway will follow a protocol signed off by the Pathway Board relevant to that tumour group, there will be equity of care across Greater Manchester as every patient follows the same schedule of tests (where clinically appropriate).
Each protocol will also include inclusion and exclusion criteria.
GM Cancer alliance have also written an Equality Impact Assessment (EIA) to ensure that PSFU does not make health inequalities worse. Trusts will also write an EIA which reflects their specific population.