Improving the Cancer Journey in Powys

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The programme aims to develop a model of care similar to one developed in Glasgow. The model will offer everyone who is diagnosed with cancer a personalised and supported conversation (called a holistic needs assessment) with a key worker who will be able to discuss and support all their needs and offer advice, information and signposting in a co-ordinated way. In addition, the programme will evaluate an electronic, holistic, needs assessment that will enable the patients numerous needs to be identified and addressed within their individual care plans.


This support could cover things like information on:


  • welfare benefits

  • returning to work

  • making a will

  • social care packages and carers assessments

  • access to occupational therapy or lymphedema health services

  • how to tell family members or children about a diagnosis or treatment

  • dealing with tiredness, fatigue or pain management

  • nutritional advice

  • best types of exercise

  • local support groups  


Along with health and care professionals and third sector partners like PAVO (Powys Association of Voluntary Organisations), the Bracken Trust and Credu, we will be developing pilot projects during 2021 and using the feedback given by all involved to better co-ordinate, signpost and support people living with cancer in the county.


The experiences of people living with cancer are at the heart of shaping this project. If you would like to share your story – either as someone living with cancer or a family member, please get in touch. You can email the project team at or call Sue Ling on 01597 826043 to have a chat and find out more about how your story will help shape the final model of care. 


Take a look at our Plan on a Page which explains simply what the ICJ in Powys programme is about.

In the video below Dylan Owen, Head of Commissioning at Powys County Council, explains how the programme came about and what it will mean for people living with cancer in Powys.

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Powys Teaching Health Board and Powys County Council are working in partnership with Macmillan Cancer Support on a three-year programme called “Improving the Cancer Journey in Powys”.


The aim is to ensure that everyone living with cancer in Powys gets the right help and support to live their life as fully as they can, by providing them with the practical, physical, emotional, spiritual, and social support they want or need so they can achieve what matters most to them.


Cancer is classed as one of the Big 4 diseases within the Powys Health and Care strategy.  In Powys there are just under a thousand people a year diagnosed with cancer.  With improvements in cancer care treatment and drugs, it is now often the case that people are living longer, and well, with cancer, and, as a result, it is important that their health and well-being needs are met.    

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19 May 2021

Cancer pilots to co-ordinate care and support launched in Powys

Four pilot projects are getting underway in Powys to test out who is best placed to co-ordinate the needs of a person living with cancer during key points in their cancer pathway from diagnosis, treatment and beyond.

Funded by Macmillan Cancer Support the four pilots - part of an innovative programme called ‘Improving the Cancer Journey in Powys’ - will involve the Bracken Trust, Credu, Powys Teaching Health Board’s specialist palliative team and the Powys Association of Voluntary Organisations.

Each person who contacts or is referred to one of the four pilots for the first time will be asked to complete what’s called an electronic Holistic Needs Assessment (eHNA).  This checklist of topics aims to capture the key needs and concerns that patients might have following a cancer diagnosis including fatigue, finances, work, diet, medication and more. The online or paper version can be completed by the person in the comfort of their own home or if easier at some of the pilot sites (once reopen) using a tablet. 

Once the assessment is completed, the top three or four concerns are discussed and a detailed care plan developed. This tailored package of support, advice and information focuses on the whole person and their emotional, practical, physical, social, and spiritual needs.

Ann Williams, Manager of the Bracken Trust which provides nursing advice, complementary therapies, counselling,  and support to around 300 people in Powys living with cancer, said: “We are pleased to be involved in the ‘Improving the Cancer Journey in Powys’ programme and have been using the paper format of the Macmillan holistic needs assessment for a number of years. We are delighted to now be able to provide it electronically which will create a more streamlined care process for the individual allowing them to have a copy to share with other people involved in their care to ensure everyone is working together. 


Clair Swales, Head of Health and Wellbeing at PAVO said: “Two of our connectors will take the lead on our pilot but will support anyone who gets in touch with a diagnosis if they haven’t already been offered the assessment through their hospital or another service.  Our connectors have local knowledge and are well regarded in their respective communities acting as champions for local people who need advice about where to go for support.  We are inspired by the potential the ICJ in Powys programme can bring to improve cancer care for Powys residents.”

Becky Evans at Credu said: “The phrase “people living with cancer” is sometimes interpreted as referring to the person with the diagnosis, but it is actually broader and encompasses those who care for the person – often a close family relative.  Our pilot will focus on the voice of the carer so as to test out how the holistic needs assessment works for them. We already know that their input and involvement is crucial in terms of the care and support given to loved ones with a cancer diagnosis.  Listening to and offering support to the carer via an assessment is a new avenue which we are keen to explore and learn from.”.


Richard Pugh, Head of Partnerships for Macmillan Cancer Support in Wales, said: “We know that Covid has placed enormous pressure on our national health service and that hundreds of people already diagnosed with cancer have had treatments postponed or surgery cancelled.  I said back in October when we launched this programme that you can’t furlough cancer. For those Powys patients who have had a diagnosis these pilots aim to offer them a tailored package of support based on their individual wants and needs.  The learning we gain over the next six months will be invaluable and further improve and develop a fit for purpose model of care for the county.”