Follow up after cancer treatment: Improving access to supported self-management through testing of a GP led Active Inclusion Pathway


Session type:


Lucy Johnston1,Dr Sineaid Bradshaw2,Rossi Durie3,Karen Campbell1
1Edinburgh Napier University,2Wester Hailes Health Centre, Wester Hailes Healthy Living Centre,3Westerhaven Macmillan Cancer Information and Support Centre



The Transforming Care After Treatment (TCAT) programme aims to improve the aftercare for people living with and beyond cancer in Scotland. It is a partnership between the Scottish Government, Macmillian Cancer Support, NHS Scotland, Local Authorities and third sector organisations. Through TCAT funding an Edinburgh Health Centre in an area of multiple deprivation devised a care pathway to standardize more pro-active access to Holistic Needs Assessments (HNA) for all people who have completed their cancer treatment and their carers.


A streamlined referral protocol ensures all patients completing cancer treatment are robustly invited to undertake a HNA with our third sector partner organization Westerhaven; a community cancer support centre. This results in a tailored Anticipatory Care Package (ACP) utilizing local health and social care and third sector resources and agencies. Working with Edinburgh Napier University patient demographics, concerns identified and assessment processes and actions, such as referral and signposting activity is being analyzed for around 100 patients.


Early findings have identified a significant improvement in the uptake of supported self management. The study identifies the physical, emotional and other concerns of both patients and importantly carers (using the HNA tool the Concerns Checklist) at this important transition period from hospital to community. In addition, health care utilization data can be presented, relating to the reduction on demands on GP time, reduction in the prescription of anti-depressants and unplanned admissions.


This is an important Scottish study within the field of cancer care and the role of the GP, working in partnership with community based organizations to facilitate transition from hospital to primary care. We will illustrate the added value of implementing such a protocol using a whole systems approach to better identify the psychosocial and spiritual requirements of patients, and reduce the burden on GP’s.