Personalised Stratified Follow-Up

Personalised Stratified Follow-Up 

Personalised Stratified Follow-Up (PSFU) – also referred to as Supported Self-Management and any number of other names – is a programme for moving follow-up care from outpatient clinics to remote monitoring.  

Men who are eligible for remote follow-up therefore don't need to attend routine appointments unless an issue arises. This saves time and money for patients and clinicians alike. 

Since the publication of the NHS Long Term Plan in 2019, the implementation of supported self-management has been an NHS commitment to make personalised care the norm. 

You can find the NHS’ own resources for Implementing Personalised Stratified Follow-Up Pathways here:  

Implementing Personalised Stratified follow-up Pathways

The True North Model 

Lead by the University of Southampton, and in collaboration with Prostate Cancer UK, the Movember Foundation, the University of Surrey and five NHS Trusts in England, a model for PSFU was developed and rolled out under the project name, True North. 

It has four key elements: 

1. Online Patient Service 

Access to an online portal that allows patients to check test results, complete assessments, view patient information and message their clinical team. 

2. Remote Monitoring 

A PSA tracking system that can alert the clinical team about missed tests and results that fall outside the personalised safe ranges, ensuring that no man is lost to follow-up. 

3. Support Worker 

A band 4 support worker acts as a key worker during their follow-up care. This person is solely dedicated to their follow-up pathway and they are critical to ensuring its safe and effective delivery. 

An example prostate cancer support worker job description can be viewed here.

4. Workshop 

A 4 hour supported self-management workshop with a group of 8 to 10 men to develop knowledge, skills, and empower confidence to manage their prostate cancer follow-up. The sessions also introduce the patient to the remote monitoring IT portal.  

Our online course is freely available to support you with delivery of these workshops:

Take the course

The Evidence 

From 2015, researchers from the University of Southampton (funded by the Movember Foundation, delivered in partnership with Prostate Cancer UK) trialled the initiative in five NHS trusts. 

The results showed that a shift to a supported self-management model of care with remote surveillance and a transition workshop; 

  • Resulted in high satisfaction levels with the model of care 
  • Meets NICE cost-effectiveness criteria 
  • Addresses capacity issues by replacing a one-size-fits-all model with a new, personalised approach for men who are progressing well 
  • Places emphasis on a positive patient role in recovery and looking after their health and well-being 
  • Patients reported equally good outcomes when monitored remotely compared to having appointments for their follow-up care. 

Read the full report here.

'How To' Resources 

Guidance Booklet 

A brief overview and guide for implementing supported self-management can be found here.

The Toolkit 

This toolkit aims to support implementing PSFU in prostate cancer, and can be tailored for other cancer services. See the toolkit here.

Resources and information can also be found via the University of Southampton website here.

Patient Case Study

Watch Daniel's story here below:

Daniel’s Story: TrueNTH Supported Self-Management

TrueNTH Supported Self-Management

Project Lead: Alison Richardson, Clinical Professor of Cancer Nursing and End of Life Care, University of Southampton. End date: March 2019 

The problem 

Men with a diagnosis of prostate cancer report high levels of unmet needs in the months and years that follow treatment, despite regular follow-up clinic attendance. Commonly reported issues include: urinary and bowel dysfunction, hormone therapy side-effects, such as fatigue, hot flushes and weight gain; loss of self-confidence, fear of recurrence, anxiety or depression; and sexuality-related unmet needs. 

Some men with prostate cancer report feeling “abandoned” by the healthcare system once their treatment is complete, and The National Cancer Patient Experience Survey (England) reported that one in four men are dissatisfied with how long they have to wait for an outpatient appointment. 

Cancer services must improve the quality of follow-up care against a backdrop of increasing numbers of men diagnosed and significant workforce challenges. 

How TrueNTH is confronting it 

The TrueNTH Supported Self-Management and Follow-Up Care project, lead by University of Southampton, has worked in partnership with University of Surrey and five NHS Trusts in England to transform the follow-up care pathway. 

Men, whose follow-up care is managed through this new programme:

  • Have access to to a support worker who acts as their key worker for the duration of their follow-up care
  • Have access to an online patient service that allows them to check test results, complete assessments, view patient information and message their clinical team
  • Attend a 4 hour supported self-management workshop with a group of 8 to 10 men to develop knowledge, skills and confidence to self-manage their condition
  • Continue to have their disease closely monitored by their clinical team
  • Do not need to attend routine appointments unless an issue arises

Our new resources 

Resource 1:

Film on the TrueNTH Supported Self-Management and Follow-Up Care project  

A short film to raise awareness about the project amongst healthcare staff, men affected by prostate cancer and the wider public. Watch here.

Resource 2:

The Toolkit: A guide to Implementing the TrueNTH Supported Self-Management and Follow-Up Care Programme 

A toolkit has been developed to support health services intending to implement this follow-up care for prostate cancer. This resource includes example clinical protocols, pathway diagrams and many other documents that services can tailor for their own use. The Toolkit can be accessed by visiting the University of Southampton website: