Integration Excellence Award

This category is for nominees and teams who have improved the coordination of services and enabled integration across settings such acute, primary, social and voluntary or through digital services, to provide a seamless experience for people living with cancer.

ESNEFT and Alvie Prehabilitation Team

East Suffolk and North Essex Foundation Trust

Image: Integration 2023 ESNEFT and Alvie Prehabilitation Team 2

Prehab is a core aspect of personalised cancer care. As well as empowering people with cancer to take control of their own care, research also shows that it results in fewer complications, reduced hospitalisations and better functional recovery.

Committed to developing a person-centred prehab model, the Cancer Prehabilitation Team at the East Suffolk and North Essex Foundation Trust initially piloted a successful programme of in-person exercise classes. Recognising that the classes alone couldn’t reach everyone who needed them, the team collaborated with Alvie, a digital health coaching app, to offer patients bespoke goal-orientated prehab. When both programmes demonstrated significant improvements in physical and psychological health, the team chose to merge them and launch a multi-modal prehab initiative.

"In order to make the model sustainable, we needed to offer that element of choice to make sure everybody with cancer was offered prehab in the way they wanted it," explains Macmillan Deputy Lead Cancer Nurse Louise Smith.

Macmillan Information and Support Team

Northampton General Hospital

The Macmillan Information and Support Team at Northampton General Hospital had always wanted to create a suite of online videos to support people with cancer at the times when their information and support centre was closed. When Covid hit and the centre was in lockdown, the team set about producing as much helpful and accessible content as they could. As the project evolved, they created a popular YouTube channel which now contains more than 80 videos. The huge library contains content based on specific cancer types as well as general concerns identified through patients’ HNAs, plus Q&A sessions with clinical teams.

User involvement has played a crucial role in the channel’s development. Not only is the centre’s patient forum a key stakeholder in the project, but patients are regularly featured in the videos too.

"There's nothing more powerful than the voice of someone with a lived experience of cancer," says Macmillan information and support lead Wendy Lilley.

Right by You Wessex

University Hospitals Southampton

People with cancer can sometimes experience inconsistent levels of care and have significant gaps in what support may be available to them. Right by You Wessex is an integrated service for anyone with cancer, providing care and support when and where they need it. Right by You works in collaboration with people so that support meets their needs and priorities, and with other health and social care professionals so that care is joined-up.

Based in two locations, Southampton and Portland, the team provides bespoke support based around individual needs. The majority of referrals involve providing complex psychosocial support to individuals and families, and the team provides advanced support utilising ACT/CALM therapy approach. The team visit people in their homes, while also providing specialist cancer support to people experiencing homeless and people in prison. Right by You improves primary care integration by offering a mentorship opportunity to practice nurses to build knowledge and confidence to deliver timely and effective cancer care reviews.

Upper Gastrointestinal Cancer Team

St Helens and Knowsley Teaching Hospitals NHS Trust

Patients with incurable upper GI cancers tend to have complex needs and a short prognosis. The St Helens and Knowsley Upper GI Team knew many of their patients were not receiving the specialist support they needed so therefore developed a bespoke nurse-led service which does things differently.

After successfully achieving support from their organisation and Macmillan, they introduced a Palliative Package of Personalised Care. This includes timely holistic needs assessments and advanced care plans, and access to a joint clinic with specialist palliative care and dietetics. In partnership with their local hospice, they also provide a relaxed health and wellbeing event known as ‘Tea with the Teams’.

The fully integrated service has helped to reduce hospital admissions, challenged preconceived thoughts around hospice care, and optimised professional inclusion along the patient pathway.

"We can't change the prognosis for patients, but we can support their journey to make their experience as positive as possible during such a difficult time," says team leadBarbara Ashall.