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Macmillan Integrated Personalised Care

About the Project

The Macmillan Integrated Personalised Care (IPC) project is a collaborative initiative involving Macmillan Cancer Support, Wirral University Teaching Hospital NHS Foundation Trust (WUTH), and One Wirral CIC. This innovative project aims to transform cancer care on the Wirral by focusing on integrated and personalised support for cancer patients. Despite better overall health outcomes compared to some areas in Cheshire and Merseyside, the Wirral faces significant health inequalities, particularly in its eastern parts.

Through the IPC project, we aim to address the gaps in support that many cancer patients experience, especially after being discharged from hospital care. This initiative leverages the strengths of multiple organisations, including the Macmillan Information and Support Service, Macmillan Wirral Welfare Benefits Service, and the Community Prehabilitation (Prehab) Service. By working together, we can ensure that every cancer patient on the Wirral receives a tailored and comprehensive care plan that addresses both clinical and non-clinical needs.

Why It’s Needed

Cancer continues to be one of the leading causes of death on the Wirral, but advances in treatment and early diagnosis mean more people are living longer with cancer. However, many of these individuals face long-term consequences from both the disease and its treatment. As of 2021-2022, there were 4,288 new cancer diagnoses at WUTH, and currently, 14,210 people are living with and beyond cancer on the Wirral.

The IPC project is crucial because it addresses several key issues identified by the National Cancer Patient Experience Survey 2022. The survey revealed that:

  • 72% of patients had a discussion about their needs and concerns
  • Only 51% felt they received enough support at home from community or voluntary services.
  • 67% were adequately informed about the possibility of cancer recurrence or spread.

These gaps highlight the need for a more integrated and personalised approach to cancer care.

The project also responds to feedback from patients who have struggled to access support post-discharge. By creating a more connected system that includes a single point of access for community support, we aim to simplify and improve the support process for cancer patients. This ensures they receive the necessary help to manage their health and wellbeing comprehensively.

Process and Desired Outcomes

The Macmillan IPC project will be delivered through a collaborative and integrated approach across primary, community, and acute care settings. The key components of the project include:

  1. Integrated Team and Workforce Models: We will develop an integrated team that works across various settings, including primary, secondary, and community care. This team will include community support workers who will have dedicated time to engage in personalised care conversations and develop tailored care plans.
  2. Single Point of Access (SPA): A SPA will be established for cancer community support, providing an efficient route for patients to access holistic support. Every cancer patient will be offered a Holistic Needs Assessment (HNA) and a Personalised Care and Support Plan (PCSP).
  3. Community Support Workers: These workers will link directly to the Macmillan Information and Support Service and other community assets. They will ensure that each patient’s care plan addresses their specific concerns and needs.
  4. System-wide Collaboration: The project will create strong partnerships across the healthcare system, including voluntary, community, faith, and social enterprise sectors. This collaboration will enhance the overall support network available to cancer patients on the Wirral.
  5. Evaluation and Continuous Improvement: We will monitor progress through various metrics, including patient activation and wellbeing scores. Regular data collection and stakeholder engagement will help us understand the impact of the intervention and guide ongoing improvements.

Through these efforts, we expect to achieve a higher level of personalisation in cancer care, ensuring that patients receive coordinated and proactive support throughout their cancer journey. By embedding this model within the existing ‘Neighbourhood model’, we aim to create a sustainable and integrated system of care that continues to evolve and improve over time.