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Improving the Cancer Journey: A Collaborative Model of Integrated Care in a Community Setting


Fiona Smith

Macmillan Cancer Support, GB
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Macmillan Cancer Support has developed a collaborative model of integrated care which crosses secondary, primary, community care and utilises community assets to provide holistic support to people living with cancer. 

Improving the Cancer Journey ICJ is an integrated multi-agency approach which includes Macmillan, Glasgow City Council and NHS Greater Glasgow and Clyde working in partnership to deliver person centred care and support outside of hospital. It is social model of care including addressing wider social determinants of health such as housing.  Anyone across sectors can refer including self-referrals.

ICJ contacts every newly diagnosed individual with cancer in Glasgow, offering them time with a link worker to discuss their support needs and to coproduce an individual care plan. This Holistic Needs Assessment HNA covers six areas of concern: physical, practical, family/relationship, emotional, spiritual/religious and lifestyle or information needs. Individuals’ three main areas of concern were money and housing, fatigue and tiredness, and mobility.

An evaluation of the first two years of ICJ found that service users reported positive changes in their quality of life and a reduction in their concerns and feelings of isolation. The report also found that:

61% of those supported by ICJ came from the most deprived category of people living in Glasgow, with another 16% from the second most deprived category.

ICJ has helped people claim almost £1.7m in financial support such as welfare payments, and write off more than £100,000 of debt.

The Scottish Government has pledged support to roll out similar services across the nation.

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 giving help with holistic needs as a single point of contact. The service is delivered in community settings and supports people to access over 230 existing organisations.


Additionally, Macmillan Cancer Support’s Recovery Package model has also been key in developing more personalised and integrated support for people living with cancer.  The model has four main interventions. Holistic Needs Assessment and Care Planning, Treatment Summary, Cancer Care Review, and Health and Wellbeing Events. These elements form part of an overall support and self-management package.

Taking the evidence, learning and key principles from ICJ and the Recovery Package, a national programme has developed with sites in England and Scotland exploring how to spread the development of integrated models of non- clinical care and support for people living with cancer which are personalised, coordinated and promote wellbeing and independence.  The programme is developing collaborations across health, social care and communities.

Important work in the programme include:

1- understanding the needs of local population and current pathways

2- understanding what assets already exist in local areas to build sustainable solutions utilising these assets

3- taking a coproduction approach with citizens and professionals to developing solutions

This workshop/discussion provides an opportunity to understand the key barriers/enablers to developing integrated programmes, the learning and to explore the outcomes for systems, organisations and most importantly for citizens. 

How to Cite: Smith F. Improving the Cancer Journey: A Collaborative Model of Integrated Care in a Community Setting. International Journal of Integrated Care. 2018;18(s2):167. DOI:
Published on 23 Oct 2018.


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