Case Study – Macmillan Personalised Care Service Team

Case Study
Macmillan Personalised Care Service Team
Great Western Hospitals Foundation NHS Trust

What was the issue/problem that needed to be addressed? 

Great Western Hospitals Foundation NHS Trust recognised there is an increasing number of cancer referrals and a growing number of patients who are living well and longer with cancer and those who have longer -term positive outcomes and are in remission.

Being diagnosed or waiting for a diagnosis for cancer and then undergoing treatment for cancer is a worrying and stressful time for patients in understanding the process. The Cancer Nursing Specialist (CNS) role in the Breast Cancer pathway for example supports the patient with their cancer pathway decision making providing information and clarity, listening to patient concerns and signposting to other help and services.

What action was taken to address the issue?

Great Western Hospitals NHS Foundation Trust has gone a step further seeing a gap in the need for more patient support and have set up a new ‘Personalised Care Service’ initially with two-year pump priming funding from Macmillan Cancer Support. This is run by two CNSs- Michelle Taylor, the band 7 Team Lead who has many CNS years’ experience in Hematology Oncology and Lauren McClelland at band 6 who previously worked as a Chemotherapy Nurse . Both were recruited from the Trust and are passionate about holistic patient care and have initially been seconded to the service for the two years.

The Personalised Care Service is borne out of the increasing demand on cancer services from new referrals and from people living longer with cancer and in remission so there is less staff time to work with patients including those with more complex needs who require more support. The new service is available to patients with any type of cancer and at any point in their cancer journey to help empower them to assist self -management and improve their wellbeing. The service is available in both the community as well as the hospital. Internal referrals come from the various trust cancer site services and the Service makes it as easy as possible for colleagues to make referrals via email with brief patient situation information. The Personalised Care Team can ring the patient direct to offer support and explain services available. There are also good links with the Macmillan Personalised Care CNS based in primary care as communication is key.

Currently the Service offers a variety of services including face-to face sessions as well as virtual workshops on areas such as mindfulness, dealing with cancer fatigue, nutrition and, smoking cessation. In addition, wellbeing sessions are offered which include areas such as complementary therapies or reflexology at the end of the session to give the patient a positive experience.  During site specific health and wellbeing days the programme is adapted to the patient group’s specific needs. For example, on the recent breast care day the Breast Care Surgeon was invited to demonstrate the correct techniques of breast self-examination.

The service has had approval to grow the team to include support from a physiotherapist and an occupational therapist so this will soon be a multidisciplinary team approach to support patients and be able to extend services and support.

The Team are making links with existing services and charities to signpost patients to for ongoing self-help. Miichelle and Lauren are supporting the ‘Skyyourway’ Charity during local park runs once a month to encourage cancer patients, their friends and relatives to ’move more and sit less’. They also intend to try and make links with local gyms who can potentially personalise exercise for cancer patients.

A cancer buddying service is also being set up for those who have had a cancer diagnosis within the last five years, or a relative who has closely supported someone in this situation to volunteer to support newly diagnosed patients and those needing more help. There has been a good response from volunteers, and it is hoped that this additional type of peer support will complement the personalised care work undertaken by the CNSs and the multidisciplinary team. The buddies will all attend a study day to explain the role and be supported through the time they volunteer. They can offer support by sitting with the patient whilst undergoing treatment on the Day Ward or be available via the phone to have a reassuring conversation.

What difficulties and barriers needed to be overcome to implement the change?

There have not really been any significant challenges. The funding has come from Macmillan Cancer Support and there have not been any issues recruiting to the new service and it has been quite positive to date as the Personalisation Care Team complements existing services. After two years it is hoped that the Trust will recognise the work and take over the pump-primed roles, so this is potentially a barrier for the Service longer-term.

What benefits have resulted from the change?

This is generally positive work and the CNS team have been given the time to set up the service. In its first three months alone, the service received 60 referrals and has developed good communication with cancer sites and with primary care which are vital to raise awareness of the Service to potential referrals. The fact that both Lauren and Michelle have worked in the Trust for many years means that they already have links and contacts. Recent wellbeing workshops have already had a good take up with more patients booked on to future ones. 

Cancer Services and other cancer staff in the trust are being very supportive and can see the value of the new service.

‘We know that being diagnosed with cancer can be a very worrying and uncertain time for patients. Some newly diagnosed cancer patients can feel overwhelmed and anxious about their diagnosis and pathway. The CNS teams are now able to refer to the Personalisation Care Service so we can all work together to help their needs and offer tailored support for improved health and wellbeing requirements’. 

Michelle Taylor-CNS CNS Macmillan Personalised Care Team 

The Personalisation Care Service is evaluating all activity from the workshops and events and from the National Patient Survey to demonstrate its impact and to continue to improve services.


Michelle Taylor-CNS CNS Macmillan Personalised Care Team

Lauren McClelland -CNS Macmillan Personalised Care Team