Personalised Care and Support Planning

Personalised Care and Support Planning (PCSP) helps people living with cancer to take an active and empowered role in the way your care is planned and delivered with interventions and care tailored around the things that matter most to you.

It is achieved through a series of supportive conversations in which you, or someone who knows you well, explores the management of your own health and well-being in the context of your life and family situation.

What are the benefits of PCSP?

Personalised Care and Support Planning will help to:

• facilitate conversations with patients
• identify their needs (with Holistic Needs Assessments)
• develop a Personalised Care and Support Plan
• share the right information, at the right times
• signpost to local support services.

The four interventions of PCSP are:

• Holistic Needs Assessments (HNAs)
• Treatment Summary
• Primary Care Cancer Review
• Health & Well-being Information and Support

Personalised care for people living with cancer (macmillan.org.uk)

What is a holistic needs assessment?

A holistic needs assessment (HNA) ensures that people’s physical, practical, emotional, spiritual and social needs are met in a timely and appropriate way and that resources are targeted to those who need them most A HNA is a simple questionnaire that is completed by a person affected by cancer. It allows them to highlight the most important issues to them at that time, and this can inform the development of a care and support plan with their nurse or key worker. The questionnaire can be completed on paper, or electronically. A HNA is also sometimes referred to as a “concerns checklist”.

A HNA may be offered around the time of a cancer diagnosis. It will probably be carried out by your Clinical Nurse Specialist or a Cancer Care Navigator.

If you have a cancer diagnosis and have not been offered an HNA, please ask your Clinical Nurse Specialist or contact the Cancer Care Navigator team on 01603 647175 or download one here.

Cancer Care Reviews

Support for people living with and beyond a cancer diagnosis does not finish at the completion of treatment in hospital. GPs and practice nurses have a key role to play in supporting patients during and following treatment.  One of the key times that they will do this is at a Cancer Care Review.

What is a Cancer Care Review?

A Cancer Care Review is a key opportunity for you to receive support from a member of your GP practice team (usually a GP or practice nurse) following a diagnosis of cancer.  It is an opportunity for you to raise any concerns you may have and to talk through your experiences. These consultations are designed to be patient-led, allowing you to discuss the things that concern you most and identifying ways in which you can help yourself or be supported by your GP practice.

Cancer Care Reviews should take place with your GP practice within six months of a cancer diagnosis and may take the form of an initial phone-call at diagnosis and a follow-up appointment within six months, but this varies from practice to practice.

A Cancer Care Review can be requested at any time by a patient not just within the six month period.  If you have concerns about living with and beyond your cancer diagnosis, or if concerns develop over time, please get in touch with your GP practice and ask for a Cancer Care Review.

What is a Treatment Summary?

A Treatment Summary is a document produced by the Doctor or Specialist Nurse at the end of initial treatment for cancer. It is shared with the patient and their GP and includes details of:

• the treatment that that person has received
• the possible / potential side effects
• the signs and symptoms of recurrence,

A Treatment Summary is completed after a significant phase of a patient’s cancer treatment. It describes the treatment, potential side effects, and signs and symptoms of recurrence. It is designed to be shared with the person living with cancer and their GP.

The Treatment Summary aims to inform the GP and other primary care professionals of actions that need to be taken and who to contact with any questions or concerns. The person affected by cancer also receives a copy to improve their understanding and to know if there is anything to look out for during their recovery.

It also provides the GP with an up-to-date and clear understanding of the patient’s treatment. This can include information that is essential for updating their records and for conducting a Cancer Care Review.

The Treatment Summary can also be shared with other health professionals and used to evidence the patient’s treatment, for example when claiming travel insurance. A copy of the Treatment Summary is retained in the patients case notes so medical staff can access the patient’s information easily if they are admitted back to hospital after their primary treatment is complete.

Macmillan “What to do after cancer treatment ends: 10 Top Tips.”