Community care coordinator project. Three women sat round a table looking at a tablet.

Macmillan-funded 'community care coordinator' project in Shropshire Telford and Wrekin ICS

Published: 02 August 2023

Claire Taylor (Chief Nursing Officer) met Tudor Humphreys (Macmillan Partnership Manager in the West Midlands) and got talking about the Macmillan- funded community care project. She asked him to write this blog to spotlight one approach to increasing holistic personalised care to people living with cancer.

Written by Claire Taylor, Chief Nursing Officer, and Tudor Humphreys, Macmillan Partnership Manager


One of the best parts of being a Partnership Manager in Macmillan is the opportunity it offers to take a seed of an idea (original discussion in 2018, project completed in March 2023) which emerges from a work focused discussion - in this case with a very experienced Macmillan GP approaching the end of her career - and despite the inevitable obstacles and cul-de-sacs (Covid-19 included), working with others and navigating the barriers and changing environment (internal and external) to bring about real change for people with cancer.

This blog will share how we made that happen in the West Midlands.


The idea was to look at how we might increase our offer of a meaningful Cancer Care Review (CCR) to enable a conversation to take place between a patient and a healthcare professional about their cancer journey. It is essential to personalised care and helps patients to:

  • talk about their cancer experience and concerns
  • understand what support is available in their community
  • receive the information they need to begin supported self-management

Whilst some critics have described a Cancer Care Review as a tick box exercise, hurriedly carried out in Primary Care by overworked health care professionals. The project team were keen to aid GPs to reintroduce CCRs as a normal part of practice, recognising the value it offers in allowing a focus on people’s social and psychological needs as well as their physical needs. A £284,000 support grant provided by Macmillan Cancer Support made this possible.

What we did

We launched the Macmillan Community Care Coordinator Project late in 2021, working closely with GP surgeries from the outset to enhance the model of community cancer care. We also engaged with people with cancer, in the spirit of “what matters to you?” as opposed to “what’s the matter with you?” and then supported those who took up the offer, to access the help they required.

This 20-month project established Community Care Coordinators in GP practices in Shropshire, Telford and Wrekin. Their roles involved offering face to face support to improve the quality of Cancer Care Reviews across the county. Since January 2022, the pilot has supported over 1,000 people living with cancer to look at the support they might need in areas such as work, finances, transport, religion, relationships, and legal advice, along with their family, partners, and carers.

Feedback was gathered through 1-2-1 semi-structured interviews and group discussions. For patients, broad open discussion questions were used to enable respondents to fully expand and describe their experiences from diagnosis through to final contact with their Macmillan Community Care Coordinator. Patients were mixed between those who had completed their care and been discharged, and those still undergoing active treatment. With consideration to the range of personal circumstances, individual motivations for engagement with the programme, and clinical needs, the semi-structured nature allowed for interviewees to lead the conversation and identify the most important elements relevant to their personal circumstances.

Impact and outcomes

The Shropshire, Telford and Wrekin Integrated Care System Communications and Engagement team were commissioned to complete the evaluation of this pilot programme. The team were asked to focus on gathering qualitative views to compliment the data and intelligence collected elsewhere and gain a detailed understanding of the views and experiences of people living with cancer. Across all interviews, patients felt that the offer of a straightforward method of communication with their Macmillan Community Care Coordinator was very helpful and should be consistently available. Clinicians recognised that for the majority, 6-12 months after diagnosis was when they felt the programme became most impactful, however they were able to identify some patients and cohorts where earlier intervention would be valuable.

Both GP practice staff and the Macmillan Community Care Coordinator team strongly agreed the programme has resulted in a demonstrated need for individual holistic personalised care. All GP practices that we spoke to as a part of this review told us that their patients had benefited from involvement with the programme, and that it had enabled clinical staff to better focus on supporting all their patients’ needs.

This pilot programme finished May 2023 and we know that within the practices that participated in the programme, Cancer Care Reviews are consistently being offered to all patients, and the quality of them has significantly improved compared to before the programme commenced.

Question Number of responses Percentage who told us 'yes'
Did the appointment meet your cancer care needs 164 95%
Did you feel the Macmillan Community Care Coordinator listened to your concerns? 164 100%
Did you receive appropriate information to help you manage your concerns effectively? 160 94%
If you were referred/signposted to services, were these helpful? 137 81%
Do you feel more supported after your meeting with the Macmillan Community Care Corordinator? 162 93%

Future aims

There are several elements of the programme that can be developed for future programmes to build upon the success of this pilot including continuing to offer holistic needs assessments (HNAs).  

The Macmillan Community Care Coordinators recruited to participate in the project have gained jobs beyond the life of the Macmillan Project. They secured similar NHSE Additional Roles Reimbursement Scheme (ARRS funded) roles in Shropshire Telford and Wrekin ICS or in equivalent roles just over the Welsh border in Powys. This means a great return on Macmillan’s investment as all the experience and learning is retained, bringing ongoing benefits for people with cancer across the West Midlands locality.

If you are a health or care professional and want to learn more about Cancer Care Reviews and Personalised Care and Support Planning please register for FREE access to the Macmillan Learning Hub. If you are already registered, access the Cancer Care Review Course.

This course is designed to help Primary and Community Care Professionals understand the benefits of a cancer care review, what elements go into making a good quality cancer care review and how to ensure the person living with cancer has their needs identified and met. 

Our Personalised Care and Support Planning Community contains information about the Supporting Cancer Care Programme, Community of Practice, Holistic Needs Assessment and many other resources.