Establishing ‘closer to home’ community nurse-led clinics for follow-up of men with stable prostate cancer

Meet Royal Surrey County Hospital NHS Foundation Trust

The Royal Surrey County Hospital NHS Foundation Trust is a specialist tertiary cancer centre, and is the lead centre for all cancer patients in Surrey, West Sussex and Hampshire, serving a total population of 1.2 million.

Cancer services are based at the St Luke’s Cancer Centre, which is recognised as a leading urology centre locally, nationally and internationally (particularly in prostate brachytherapy). The centre is focussed on innovation and the introduction of minimally invasive treatments. It has recently introduced brachytherapy, laparoscopic radical prostatectomy, cryotherapy and high-intensity focused ultrasound.

Around 200 men a year are diagnosed with prostate cancer within the Trust, with around 4,000 accessing follow-up treatment annually.

The big idea

This project focussed on improving the links between the hospital and community and primary-based care - follow up (the primary focus), and referrals were target areas.

Currently all prostate cancer follow up patients in the Trust are seen within secondary care and there are no follow-up systems in the community. Communication is generally poor between primary and community care and the Trust.

The service will build on national work looking at the risk stratification of prostate cancer patients, shifting stable and low risk patients to community-based care. This shift is particularly important in prostate cancer, given the high numbers of men undergoing active surveillance and watchful waiting.

It will also bring the quality of the Royal Surrey’s follow up care into line with the quality of treatment it offers. To achieve this the project will set up follow-up clinics in community care and nurse-led telephone clinics, offering full prostate assessment (including urinary flow rate; symptom score; DRE; urinary dipstick; PSA tests), as well as holistic review (including lifestyle advice), and referral onto secondary care where necessary.

They will act as link between GPs and secondary care and offer on-going support and care for men and their families.

They will liaise with and support the local prostate charity and evaluate the overall effectiveness of this model.

Finding out what works

The project work has included the following:

  • Scoping exercise of current service
  • Meetings with Clinical Commissioning Group (CCG)
  • Presentation of project post at GP education days
  • Establish community, telephone and Trust nurse-led clinics
  • Selection of patients by risk stratification & referrals from colleagues
  • Use of HNA’s, IPSS and IIEF scores
  • Establish and build on links with local GPs
  • Development and use of patient feedback surveys

Lessons learnt

Challenges in setting up this project have included the following:

  • Arranging meetings with the CCG to discuss the establishment of community clinics
  • Finding venues both within the Royal Surrey County Hospital and community
  • Getting the go ahead to set up clinics
  • Getting access to GPs to establish clinics
  • Encouraging consultants and CNSs to refer stable prostate cancer patients for community follow-up
  • Regular emails sent to all urology & oncology consultants, registrars, clinical fellows and CNSs
  • Asking consultant secretaries to notify the project manager of suitable patients when typing GP letters
  • Urology Business Manager to put Community Clinic referrals on next Departmental Meeting agenda
  • Trawl of oncology clinics to find stable PC patients and those on long term hormones


Some of the outcomes from the project include the following:

  • Follow-up care shifted to primary and community settings. Burden on secondary care reduced, allowing patients to receive care ‘closer to home’
  • Men have an improved experience of care through:
    • Continuity of follow-up care increased
    • Patients move seamlessly into community clinics
    • Men are better informed in symptom management, HNA’s undertaken, health promotion and awareness discussed – healthy eating, physical activity and stopping smoking. Referrals made to other services when required
    • Men and their families more fully supported during follow-up care
  • Improved links between primary and secondary care
  • GPs and practice nurses more aware of prostate cancer and referral pathways
  • Support of local prostate cancer support group by CNS, improving quality and scope of support it offers to men
  • Use of patient feedback surveys to identify improved experience of care

Benefits of the community clinics

  • New innovative service
  • Previously patients were not routinely offered written information and advice
  • They cater to the patient demographic (the majority of patients are elderly)
  • Distance patients travel from home to clinic decreased
  • Cost of travel to community clinic compared to RSCH or St Luke’s Cancer Centre decreased
  • Cost of car parking at community clinics – either free or greatly reduced. Recent survey of hospital car parking showed the RSCH as most expensive in England at £4 per hour.
  • Finding somewhere to park at RSCH is also a big problem, patients panic they will be late for their appointment and become stressed and upset or angry. They are often intimidated visiting large hospitals
  • Waiting times to be seen at Community Clinics much shorter, with the majority of patients being seen within 5 minutes of their appointment time, compared to historical data of up to 2 hours at consultant clinics.

Community nurse-led clinics meet the needs of this group of patients in a more efficient and cost effective way compared to traditional consultant clinics.

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.