North Bristol NHS Trust

Implementing an integrated model of survivorship into the care pathway

Meet North Bristol NHS Trust

North Bristol NHS Trust (NBT) is an Acute NHS Trust which is directly commissioned to provide services in nine main cancer groupings. NBT participated in the National Cancer Survivorship Initiative (NCSI) during 2011/2012, piloting innovative approaches to follow-up care for breast, prostate and colorectal cancer patients. The NCSI demonstrated that this approach could bring improved patient outcomes, productivity and cash savings. The aim of this funded project was to deliver the comprehensive roll-out of innovative approaches to follow-up developed through the NCSI initiative across the whole care pathway; aligning work in primary and specialist care around the same plan.

The big idea

NBT felt that the existing cancer follow-up pathway was not sustainable with increasing numbers of new diagnoses, as there was no unified follow-up pathway for men coming out of active treatment. The aim of this project was to implement an integrated model of survivorship into the care pathway for every man diagnosed and treated for prostate cancer at North Bristol NHS Trust (NBT) as per the National Cancer Survivorship Initiative.

This integrated model involved: 

  • Redesigning aftercare services so that all patients are stratified to an appropriate pathway based on clinical and individual needs and preferences.
  • Developing supported self-management pathways for all those living with and beyond prostate cancer. 

We funded a CNS (0.6 FTE) and an Assistant Psychologist (0.6 FTE) to deliver the project.

Making it happen

The team achieved an improved model of follow up care for prostate cancer patients by:

  • Undertaking Holistic Needs Assessments and care plan reviews at key points in the pathway, allowing for individual patient needs to be identified and addressed.
  • Stratifying patients to an appropriate pathway, so that their individual clinical needs are met.
  • Providing treatment summaries, which give GPs and patients asuccinct record of their diagnosis, treatments, potential side effects and contact details for where they can get additional support.
  • Offering information and advice on health and wellbeing pre and post-treatment through Living-well events (more information below) and signposting to local support services, to increase men’s ability to self-manage.
  • Improving access to clinical and non-clinical support services, ensuring men can access the services they need to live with and beyond their diagnosis and treatment.
  • Ensuring that patients on a self-management pathway continue to be remotely monitored by the specialist team reducing the need for face-to-face follow-up.
  • Providing information about prostate cancer and the project/pathway to GPs through meetings, such as Survivorship Network meetings, and local GP events, to increase awareness of prostate cancer, this project, and the range of services they can refer patients.

The team ran Living-well days four times are year for four and a half hours. The agenda consists of speakers such as dieticians, physiotherapists, erectile dysfunction specialists, clinical health psychologists, urologists and the Macmillan 1 to 1 support team. The aim was to empower patients to better understand their disease and support the self-management process.

The Living-well course led on from the Living-well day. Patients could self-refer on the day if they felt it would be of benefit to them. The course consisted of five weekly sessions of two and a half hours, followed by a three month follow-up session. They were run by a psychologist, CNS and patient tutor. These sessions were interactive, covering topics including setting short-term and long-term goals that support recovery and survivorship, as well as information on relaxation, managing fear and anxiety, communication and relationships, PSA and Gleason and sign posting so patients know where to access more information or support.

Lessons learnt

  • It’s important to plan in advance at the start of the project and specifically establish clearly what you want to achieve and how you will achieve it.
  • Agree evaluation plans and tools at the outset of the project.
  • Involve everyone in the team from the start of the project and provide necessary training.
  • Establish a steering group at the very start of a project and gain member commitment to attend the group. This will group will provide a good foundation and help guide future direction of the project.
  • Setting up a new clinic for eHNA and treatment summaries ensures patients have enough time to complete these away from other appointments.
  • Statistics SPSS package is very useful for psychometric analysis.
  • Integrating survivorship activities into the prostate cancer follow-up pathway has meant they will continue to be delivered by other Clinical Nurse Specialists within the Urology team.


The team collected psychometric data at assessment (start of Living-well course) and reassessment (end of course). They did this using the hospital anxiety and depression scale (HADS) and an adapted version of the patient activation measure (PAM), with the latter used to measure confidence in self-managing condition.

Paired-samples t-tests were conducted with results showing:

  • A significant difference in HADS anxiety scores [t (28) = 2.85, P = 0.008 (2-tailed)]
  • A significant difference in HADS depression scores [t (28) = 1.72,P = 0.096 (2-tailed)]
  • There was no statistical significance in the Patient Activation Measure scores at assessment and reassessment stages. However, there was a very small sample size and previous data analysis of a larger patient cohort receiving the same intervention, suggests a statistically significant difference in activation over this period of time.

A questionnaire was also sent to approximately 40 men who attended an eHNA and Treatment Summary clinic, and had received a treatment summary. Overall data suggests improved health and well-being as a result of attending the clinic.

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.