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Idea Exchange: How we’re integrating person-centred care for people living with cancer

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flowers fiona for web

flowers fiona for web

Fiona Flowers

Fiona Flowers, specialist advisor for community settings, Macmillan Cancer Support, explains how Macmillan’s multi-agency Improving the Cancer Journey project offers support with people’s holistic needs

Macmillan Improving the Cancer Journey

Objective: To improve outcomes for people living with cancer and improving integrated support, working alongside Glasgow City Council and the NHS

Timescale: Five years and ongoing 

Contribution from local authority: Time, leadership, capacity

Participants: Macmillan, Glasgow City Council, Wheatley Group (housing provider), NHS Greater Glasgow & Clyde, Glasgow Life and other charities


Macmillan Cancer Support and Glasgow City Council are working in partnership with other system leaders across acute, primary and community care, including those in housing, to improve outcomes for people living with cancer (PLWC). To truly enable integrated personalised care for people living with cancer, Macmillan recognises local authorities are in a unique place to broker local solutions for people, their carers and communities given their role as convenors of place.

This has become more urgent as there are now 2.5 million people living with cancer in UK, with people living longer and the illness increasingly becoming a longterm condition for many people. Additionally, 70% of people living with cancer also have another long-term condition, as Macmillan’s April 2015 research, The Burden of Cancer and Other Long-term Health Conditions, showed.

“ICJ is helping the very people with cancer who need the support the most – 77% of people using the service are from the most deprived areas in Glasgow”

Cancer affects every aspect of your life, with diagnosis turning everything upside down in a few minutes. It can affect your personal relationships, work and finance and has a huge emotional impact with many people unsure how to describe their cancer and talk about it to others.

Our flagship collaborative model, Macmillan: Improving the Cancer Journey (ICJ), crosses secondary, primary and community care. It utilises community assets to provide holistic support to people living with cancer. Macmillan ICJ is an integrated multi-agency approach which includes Macmillan, Glasgow City Council, NHS Greater Glasgow & Clyde, the main housing provider (Wheatley Group), Glasgow Life and other charities. The partnership recognised that getting the right support for people living with cancer would also have implications for population health and other long-term conditions, as well as recognising the opportunities to use cancer to test system change.

There are six link workers who work across community and clinical settings.

Due to the proven cost savings for the housing providers they have also seconded a professional as a support worker.

macmillan logo 2019

macmillan logo 2019

This Idea Exchange was supplied and paid for by Macmillan Cancer Support 

ICJ contacts every individual diagnosed with cancer in Glasgow, offering them time with a link worker to discuss their support through a holistic needs assessment (HNA) and to co-produce a care plan which is owned by the person living with cancer and shared with the relevant professionals. Clinical professionals in secondary and primary care also signpost and refer people to the service, and the link workers can support people back into these services as appropriate.

“Key to the success has been a joined-up approach between relevant organisations, the offer of support at the earliest opportunity, and the provision of a link worker as a single point of contact”

The HNA covers six areas of concern: physical, practical, family/relationship, emotional, spiritual/religious, lifestyle and information needs. In Glasgow, people’s three main areas of concern were money and housing, fatigue and tiredness, and mobility.

The evaluation shows that:

● ICJ has helped people claim almost £13.5m in financial support such as welfare payments, and write off more than £100,000 of debt;

● ICJ is helping the very people with cancer who need the support the most – the Scottish Government’s tool for identifying deprivation (the Scottish Index of Multiple Deprivation) shows 77% of people using the service are from the most deprived areas in Glasgow;

● ICJ patients’ level of concern drops significantly, both statistically and clinically, and reduces distress to a manageable level;

● Evidence from the EQ5D instrument for measuring generic health status demonstrates significant improvement in quality of life post ICJ intervention;

● by addressing housing concerns early ICJ has prevented anyone losing their home avoiding costs of up to £5m;

● ICJ has supported people to go back to work when they want to, which is having a direct impact on the local economy;

● clinicians have said ICJ has supported them to regain focus on clinical issues and saved clinical time while improving job satisfaction and morale.

Onward referrals have been made to more than 220 organisations in Glasgow which provide further support. ICJ is delivering on the Scottish Government’s nine national health and wellbeing outcomes as part of its plans to integrate health and social care and the Scottish Government has pledged its support for the model and used it as an example of best practice.

Key to the success of ICJ has been a joined-up approach between relevant organisations, the offer of support at the earliest opportunity, and the provision of a link worker as a single point of contact.

The evaluation demonstrates that there is a shift in the balance of care from the acute sector to community and in supporting the integration of health and care.

It is demonstrating the key importance of secure and appropriate housing support, supporting people living with cancer and their families to remain in their own home for longer, thus preventing homelessness.

Key enablers have been:

● strong leadership and champions across all organisations;

● buy-in from partners and champions across all organisations;

● the skilled workforce;

● the workable process.

The learning from this programme is being explored in other areas such as drug and alcohol interventions as well as exploring sustainability and learning for other long-term conditions.

Taking the key principles from ICJ, we have developed a national programme called the Macmillan Local Authority Partnership Programme (MLAPP).

MLAPP has been working with local authorities in both England and Scotland, exploring how to develop integrated models of non-clinical care and support for people living with cancer which are personalised, co-ordinated and promote wellbeing and independence. The programme is developing collaborations across social care, health and communities.

Similar to ICJ, important areas of work across the MLAPP programme include:

● understanding the needs of local population and current pathways;

● understanding what assets already exist in local areas to build sustainable solutions utilising these assets;

● taking a co-production approach with people living with cancer and professionals to developing solutions.

The programme is being evaluated by the consultancy SQW and the Social Care Institute for Excellence and we have developed a toolkit which shares the learning. It can be found at



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