Personalised Stratified Follow-Up

A Global Initiative

Discover more about Movember's True North initiative and our work across the major factors of prostate cancer care

About True North

True North Supported Self-Management

This cost-effective programme for personalised stratified follow-up delivers better outcomes for prostate cancer patients and has been shown to free up capacity in the follow-up pathway. 

The programme moves 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.

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 to missed tests and results that fall outside the personalised safe ranges, ensuring no man is lost to follow up. 

3) Support Worker

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

An example job description can be viewed below.

Prostate cancer support worker job description

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 introduces 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 show 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

Click here to view

The Toolkit

This toolkit aims to support implementing stratified follow-up in prostate cancer, and can be tailored for other cancer services

Click here to view

Patient Case Study - Daniel's Story

Royal Cornwall Hospital

The Royal Cornwall Hospital is one of five NHS Trusts that took part in the pilot programme. Read more about it here. 

Learn more