Activities• Symptom management• Psychological/emotional

support (Macmillan Support, 2007)

• Information & education• Carer support• Physical activities• Supported self-management

• HOPE courses• Personalised care planning• Health & wellbeing• Holistic Needs Assessment• Sign posting• Medication review• Data collection

Implementation• Rolling educational programme delivered to Suffolk Community

Healthcare staff covering topics such as symptom management and the consequences of treatment

• Identification of key stakeholders within primary, secondary and voluntary sectors

• Developing robust communication links with key stakeholders• Pathway, care plans and guidelines developed (as below)

(National Institute for Health and Clinical Excellence (NICE), 2004)

Transforming Cancer Care in the Community: The Suffolk Experience

Background• Community-based project supporting cancer patients and their carers

locally, from point of diagnosis through to survivorship and self-management (Department of Health, 2013)

• Part of a larger pilot across East Anglia, consisting of 7 pilot sites• Joint project between Macmillan Cancer Support and Strategic Clinical

Network• Suffolk pilot is Macmillan funded, hosted by Suffolk Community

Healthcare• Service was set up across 3 localities each covering a population of

approximately 50,000 • Localities chosen to reflect demographic differences to ensure a broad

overview of cancer population in Suffolk

ReferencesDepartment of Health (2013), Living With and Beyond Cancer: Taking Action to Improve

OutcomesDepartment of Health, Macmillan & NHS improvement (2010), The National Cancer

Survivorship Initiative VisionMacmillan Support (2007), Worried Sick: The Emotional Impact of CancerNational Institute for Health and Clinical Excellence (NICE), (2004), Guidance on Cancer

Services: Improving Supportive and Palliative Care for Adults with CancerNHS Improvement (2013), Innovation to implementation: Stratified pathways of care for

people living with or beyond cancer- A “how to guide”

Lessons Learned• Effective multi-disciplinary team (MDT) working is essential• Utilise networking opportunities to embed service with key stakeholders• When recruiting to the team, aim for a varied and balanced skill-set• Establish clear lines of communication between acute and community

teams• Ensure that professional boundaries are recognised and maintained

within the MDT• Explore and identify local area and resources, i.e. voluntary sector

organisations, support groups• Develop a robust and effective data collection tool which reflects the

breadth and depth of service delivered• Allow sufficient time to develop and establish the service before taking

on a caseload• In order to create a sustainable service, it must be generalizable, and fit

with long-term commissioning intentions within broader community services

“I couldn’t do it without help and I feel I am getting help.”

NHS Improvement (2013)

Authors: Sarah Orr, Sadie Gillingham-Jones, Ina Malan & Astrid CoxonDate prepared: 23/10/2014

“Just pick up the phone and there is always help on the other end of the line. The word ‘CANCER’ doesn’t hold the fear that it used to.”

Department of Health, Macmillan & NHS improvement (2010)