Driving Momentum:
Transforming Care After Treatment (TCAT)
Alison Watt, TCAT Project Lead (Fife)
Debbie Provan, Regional TCAT Lead (WoSCAN)
Gordon McLean, Programme Manager (Macmillan)
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Transforming Care After Treatment
5 year programme
• Scotland wide agenda to transform care and an exemplar model of integration
£5m programme fund
• Supported by investment from Macmillan
Delivered in partnership
• NHS Scot, Scot Govt, Cancer Networks, Social Work Scotland, People affected by
Cancer, Cancer Coalition
Shared model of development
• Design, test, evaluate and roll out new models of care
The overall aim of TCAT is to ensure that people affected by
cancer in Scotland, are prepared and supported to live with
the consequences of the diagnosis and its treatment.
Scottish Cancer Taskforce
To provide national leadership in
the shaping and delivery of the
partnership between Macmillan
Cancer Support and the Scottish
Government to transform cancer
care after treatment.
Supporting delivery
across three networks
providing a mechanism
for Programme Manager
and Network Project
Managers to discuss
delivery
Operation
Support
Group
WOSCAN
Project Group
11 Projects
Evaluation Advisory
Group
TCAT Programme Board
Patient
Experience
Board
NOSCAN
Project Group
4 Projects
To innovate and strengthen the
approaches
used
to
involve
patients, carers and the public in
the development of the cancer
TCAT programme and hold the
Programme Board to account for
delivering improvements in patient
experience.
SCAN
Project Group
9 Projects + 1 National
Definition, delivery and evaluation of test / evaluation pilots
Supported by appropriate Project Governance Framework incorporating Network
Leads , Managers, Macmillan Development Managers and appointed Project Managers
Edinburgh Napier
University
Risk
Stratification
Assessment &
Care Planning
Transitions
Rehabilitation
End of Life
• New models of follow up based on individual need
• Holistic Needs Assessment
• Explicit preparation for care post treatment
• Access to information and support
• End of Treatment Summaries / Cancer Care Reviews
• Enablement Support / Health & Wellbeing Clinics
• Community based emotional/practical support
• Work & Finance / Nutrition / Physical Activity
• Support to self manage / Managing late effects
• Alignment with broader Government agenda
• Choice / dying at home
Phase 1 Projects
My Cancer Portal
H&N, Prostate &
Colorectal HNA & H&WB
Prostate HNA &TS
Lung Palliative Care
Breast HNA
Breast & Colorectal
TS, HNA, H&WB
Lung – PROM,
F/UP H&WB
Skin F/Up & TS
Most Cancers
Recovery Clinic
All Cancers HNA, TS & H&WB
Top 10 Concerns Within Secondary Care Setting
Phase 2 Projects
National TYA –
TS & HNA
All Cancers –
Looking Forward
Community Outreach
Cognitive
Rehab
Supported Self
Management
CoT
Self Management
Support
Service Co-ordination
Employability Support
All Cancers Building Connections
All Cancers Individual Budgets
All Cancers CCR
PC – HNA & Self Management
Living Well After
Treatment
All Cancers –
Reablement
Phase 3
• Focus on spread and embedding learning from 1st two phases
• Distribution of funds through shared decision making process with
key stakeholders
• Driven by Regional Cancer Networks
Cancer Experience Panel
• Represent and empower service users to take a role in strategic
decision making and care planning
• Support local service user reference groups and provide
representation at regional level
• Promote the value of service user involvement at every level
• Equal partner in allocation of Phase 2 funds and key stakeholder in
Phase 3 process
Sustainability
• Challenges
• Financial constraints
• Spread to areas out with TCAT
• Approach
• Learn and share events: national, regional, local, and topic specific – cognitive
rehabilitation, treatment summary, HNA
• Links to, and involvement of, Managed Clinical Networks
• Wider partnership working
• Demonstrating efficiency – outcomes including economic impact (9 projects)
• Service user experience
• Communication strategy including evaluation outcomes via regional and national
channels, infographics and media work
TCAT Case Study from Phase 2
RR and her son JR
•
•
•
•
•
•
Referred to the TCAT service from the Social Work Contact Centre
Diagnosed with breast cancer but had a previous diagnosis over 10 years ago
Lives centrally in a large town with 19 year old son (JR)
Experiencing physical difficulties due to side effects of cancer treatment
Feeling unsupported and had difficulty accessing local support services
Feeling concerned about her son in his caring role as he was also studying at
college
• Holistic Need Assessment (HNA) completed
JR son of RR
• 19 years old. Living at home with his mum
• Sister does not live locally but supports her brother on the
phone i.e. texts
• Carer for his mum, i.e. taking on household tasks
• Studying full time at college
• Did not know where to access support but knew support
was available
• Carer Self-Assessment completed
The Cancer Journey – Discussion
• Individually, using the HNA - tick the boxes which you feel are RR’s
concerns. As a group discuss the highlighted concerns from your table’s
perspective and what your role is in RR’s cancer journey. Use the Cog
diagram plot RR’s cancer journey thinking about the person, working
together, communication and resources
The following questions may assist you;
• What is your role in RR’s pathway?
• Who should you communicate with and how?
• Who do you expect to communicate with you and how?
• What is the driver for the Cogs
Cog Diagram Outlining
RR’s Pathway
Community
Palliative
Care
CNS
GP
College
OT
RR,
JR
LAC &
HNA
Teenage &
Young Person
Psychologist
Community
Befriender
Hobbies &
Outings
Community
Listening
Service
[email protected]
[email protected]
[email protected]
http://www.gov.scot/Topics/Health/Services/Cancer/TCAT