Enhanced primary care-led prostate cancer follow-up

Meet the team

This project was led by London Transforming Cancer Services Team for London (TCST) and involved a wide range of delivery partners including Croydon Clinical Commissioning Group, primary and secondary care clinicians and patients.

The transformation of cancer services is one of the four strategic aims for London and the TCST are responsible for the successful delivery of the five-year cancer commissioning strategy which supports the transformation of services for cancer patients in London. Priority areas for the strategy include early detection and symptom awareness, reducing variation and living with and beyond cancer.

The big idea

The National Institute of Clinical Excellence recommends that patients stable at two years after radical treatment and patients who are undergoing “watchful waiting” are offered follow-up outside of hospital in an appropriate setting (NICE Prostate Cancer: CG175 2014).

Primary care is an obvious choice for most as it enables care to be delivered in a setting where other long term conditions are now predominantly managed.

A review of patients that were already being followed-up in Croydon showed that whilst patients were satisfied with their follow-up care, the majority have not received relevant information regarding the change in their care, the potential side effects and consequence of treatment or signposts to psycho-sexual, social and incontinence services.

The project therefore aimed to develop the role of primary care nurses and GPs so they are able to offer follow up support. Also to improve the patient experience and ensure there is assessment of holistic needs and ensure men are getting the care and support required.

Making it happen

Locally arranged GP clinical network meetings provided an opportunity for the project team to discuss issues around:

  • The existing pathway
  • The quality of information provided from the hospital
  • The opportunities to sustain the enhanced service
  • The GP’s views of a holistic model adapted for primary care.

The prostate cancer Local Enhanced scheme was revised in light of issues raised and launched under a new Local Incentive Scheme (LIS). The incentives were increased to reflect the additional impact on GP and nursing time; due to the introduction of a 30 minute Welcome Appointment with a practice nurse for newly transferred patients and a 20 minute PSA follow-up appointment with the GP or nurse.

A series of tools and resources to support the delivery of a holistic follow-up service were produced and full details and templates are available here

Practices that sign up to the new incentive scheme are required to:

  • Use the patient identifier guide to identify suitable patients on practice lists that could be discharged from secondary care follow-up to primary care follow-up.
  • Offer a 30 minute ‘welcome appointment’ to all newly transferred patients within four weeks of discharge from secondary care with the primary care nurse or GP. This is an opportunity for the practice to start a holistic care plan developed for the project which should be reviewed at subsequent follow-up consultations.
  • Conduct PSA blood tests and relay results to patients via a PSA consultation appointment using the bespoke PSA follow-up template specifically Reduce/eliminate the risk of patients being lost to follow up in primary care by using the mandatory prostate cancer disease register.
  • Invite patients, GPs and practice nurses to complete a survey and send directly to the Transforming Cancer Services Team as part of a full evaluation process of the entire service.

It is recommended that at least one primary care nurse and one GP per practice complete a minimum one hour training session accredited by BMJ Learning to refresh training gaps.

Lessons learnt

Identifying patients who are stable post-treatment or on watchful waiting was challenging. The team worked with both primary and secondary care to set up a process to overcome this. Involving local clinicians and practice managers in the development of tools to support the project has resulted in less resistance to their use.

Clinicians are not always confident in managing this patient group especially in regards to discussing holistic and supportive needs. Provision of free and easy to access e-learning modules ensures that clinicians have the skills and knowledge needed.

Clinicians are often confused about interpretation of PSA results after treatment. Good quality transfer letters from secondary care will mitigate against this as well as a process to seek advice from secondary care clinicians if required.


The model demonstrated the feasibility of a primary care led follow up for stable prostate cancer patients. A local incentive scheme with initiatives to share best practice and reduce variation was developed and 57 of the 59 practices in the Croydon area have enrolled. The remainder two practices will consider enrolling in the new financial year 2016/17.

The project aimed to improve the patient experience by improving communication to patients with a welcome pack, welcome appointment and emphasis on addressing holistic needs as part of the on-going follow up. Results from a patient experience survey indicated that patients are generally happy with the service and their transfer to primary care. At the end of the project phase, over 70 patients were transferred to primary care and 49 face-to-face Welcome Appointments were conducted.

The number of patients followed-up in primary care under the new holistic arrangement is 527. This included patients that were already receiving primary care follow-up.

Training and development for primary care professionals on prostate cancer and the needs of patients living with and beyond cancer was developed. Only 17% of professionals who were surveyed completed these, and a requirement to attend an event and/online module and subsequent audit would be recommended for consideration by commissioners as part of the planning process.

An economic evaluation was conducted comparing the costs of the new primary care pathway and the local incentive scheme against the secondary care pathway. The new pathway provides a direct healthcare costs saving of 57% per patient over a five year period. This is due to a decrease in both the use of expensive consultant appointments and requirements for hospital transportation in the secondary care pathway.

Moving forward

The model has been endorsed by the pan London Cancer Commissioning Board and is currently being adapted in various CCGs across London and West Essex.

Find out more

This project has been funded through our Health and Social Care Professionals Programme, thanks to support from The Movember Foundation.

If you would like to learn more about this project please contact us.