Introduction of a new survivorship pathway

Meet Guy's and St Thomas'

Guy’s and St Thomas’ (GSTT) is a large, central London NHS Foundation Trust; it encompasses two major teaching hospitals – Guy’s and St Thomas’.

The Trust serves the London boroughs of Lambeth, Southwark and Lewisham, as well as providing specialist tertiary services for cancer patients from further afield. GSTT has been developing solutions to improve prostate cancer survivorship for over five years.

It also has extensive experience in survivorship for other cancers, and was a pilot site for the NCSI on colorectal cancer. Its ‘one-stop’ urology service is award-winning and recognised internationally as offering exemplary care.

The big idea

A survivorship pathway, that includes the recovery package for the prostate cancer patients at Guy's and St Thomas’ has been redesigned and implemented. The new pathway is more efficient and cost effective for patients and the Trust.

The recovery package includes ensuring patients have access to Holistic Needs Assessments, treatment summaries and well-being events.

Making it happen

This new survivorship pathway has been based on findings from patient and allied healthcare professional focus groups to ensure patients needs and concerns are addressed.

As a result, the pathway now involves the delivery of the following seminar sessions:

  • Pre treatment seminar sessions (all treatments)
  • Post robotic surgery seminar session (erectile dysfunction and continence)
  • Post treatment seminar session (well-being event)
  • Discharge seminar (all prostate cancer patients)

This new pathway is:

  • Providing tailored support to patients and their carers
  • Providing a smother transition for patients from secondary to primary care post-treatment

The new pathway also ensures there are clear links and interactions between primary and secondary care.

Finding out what works

It was important to make the changes that the CNS introduced sustainable. The key to this was embedding the pathway into current practice.

  • The seminar sessions are a tick box referral on the outcome forms – patients are given an appointment to attend the seminar session when they hand in the clinic outcome form.
  • Each seminar is integrated into the existing patient appointment system and is counted as an outpatient appointment.
  • The Urology Nurse oversees each seminar session.
  • All members of the multidisciplinary team take responsibility for their own session. (A/L and sickness cover)
  • The seminars are on a rolling agenda.
  • Letters are templates.

There were several challenges including changing peoples’ attitudes and the way they work and communication between secondary and primary care.

Many were overcome by holding regular meetings with different groups to identify problems and agree the way forward. These meeting included:

  • Individual 1:1 meetings to discuss how current practice needs to change and identify the best ways to address the issues
  • Regular steering groups
  • Focus groups with professionals and patients
  • Chairing 6/52 HNA meetings
  • A GP event on prostate cancer concerns was organised to help build better links with primary care and ensure they are able to provide suitable follow-up care once patients are discharged.


The project has made the new pathway sustainable by embedding it into current practice. Cost saving are estimated to be around £44,000 due to the multidisciplinary approach. These are currently being reviewed by the project team

Some of the key results are:

  • It has improved patient experience

99% of patients feel more supported and more confident in coping with their recovery after they attended the seminars.

100% of men felt more confident in coping and understanding the discharge process after they attend their discharge seminar.

Men found group sessions invaluable, and placed great value in peer support and the overall interaction.

  • There were no differences between ethnicities discussing personal issues.
  • A retrospective audit showed a 100% reduction in new referrals to andrology and continence over a six month period, reducing the bottlenecks in outpatients.
  • Patients are being streamlined to the appropriate clinics if required for further intervention within an acceptable timeframe.
  • 250 extra ED and continence patients a year are seen without any extra resources.
  • Secretarial time has been reduced as the seminars are template letters instead of individual clinic letters.
  • GSTT is compliant with the matrix’s set by the London Cancer Alliance and NCSI ‘Recovery Package’ initiatives.

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.