Innovation Exchange

Improving the Cancer Journey


Key activities

Benefits and impacts


Improving the Cancer Journey (ICJ) is a new service the council launched on 5th February 2014. This Holistic Needs Assessment (HNA) service provides direct assistance, advice and information to cancer patients in Glasgow, their families and carers to ensure no one in Glasgow faces cancer alone.


The main objectives of ICJ are to develop and deliver: clear, seamless and accessible pathways of care that are accessed timeously and appropriately, across organisational and professional boundaries, based upon robust holistic assessment of need.


ICJ is a partnership between GCC, Macmillan Cancer Support, GG&CNHS, Glasgow Life, Cordia, Wheatley Group and Prostate Cancer UK.

Themes: Health and Social Care

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Glasgow has approximately 20,000 citizens living with cancer; when including families and carers this increases to 70,000.  ICJ was developed as research advised of the growing need and complexity of issues faced by people affected by cancer (PABC).


The aims of ICJ within the 5 years of the programme are to:


  • Invite all with a new cancer diagnosis in Glasgow to have an HNA and individual care plan developed.
  • Provide the support of a dedicated named Link Officer to everyone with a cancer diagnosis.
  • Facilitate the delivery of effective Health and Social care support solutions, based on HNA outcomes.
  • Identify ways to improve service delivery for PABC


Baseline research was carried out by the NHS Health Improvement team; patients, carers and medical staff provided 100% support for the proposed development of ICJ and the link worker model being delivered uniquely within a social care setting.


A steering group with representatives from all partners informed the development of ICJ. In addition, we have established a service users advisory group where patients, their families and carers are actively involved in informing and shaping solutions


The ICJ programme is fully funded by Macmillan Cancer Support for 5 years and a robust business plan was developed to support this funding bid.


ICJ has a number of structures supporting the development, including:


  • A governance board chaired by the Executive Director of Financial Services and including Directors from all  partners who form the decision making body
  • Steering group with representation from all partners who shape and inform the development and delivery
  • Staff have been at the forefront of the development of ICJ since the programme began and through action learning sets and reviewing case studies inform ICJ developments
  • Patient reference group who provide an expert voice on what needs to change to improve the cancer journey


One of the main barriers to accessing ICJ was data sharing between NHSGG&C and GCC. To overcome this, ICJ established a data sharing protocol between the NHS and GCC. This inventive approach allows the NHS to share information on all new cancer diagnosis within Glasgow with the ICJ service. This provides access to ICJ for all PABC at diagnosis.


A robust business plan was developed to secure the £3.2 million funding for the 5 year programme. In addition, Prostate Cancer UK has provided additional funding to enable us to develop the service even further.


ICJ was initially a pilot covering 5 cancers, independent evaluation was carried out by St Andrews University. The results from this informed a board decision to extend to all cancers in October 2014.

ICJ is the first service in the UK to utilise the HNA within a local authority context.


By adopting the HNA, Distress Thermometer and Care planning tools, ICJ delivers a person centred approach to assess, review and connect Clients to appropriate support services which delivers better outcomes for PABC.


Partnership working has been instrumental in the development and delivery of the ICJ service. Through our partners, ICJ are able to deliver their vision and aims by providing clear pathways that utilise and integrates existing services. To date ICJ have worked with over 100 agencies in Glasgow to deliver tailored care plans for our Clients.


ICJ developed a bespoke Case Records Management System which links to the SWS CareFirst system. The system was designed specifically to meet the reporting needs of ICJ; providing the ability to record and report detailed information about the client’s needs, outcomes and impact of ICJ. The system is a rich source of data which helps to better understand needs of PABC. ICJ are early adopters of tablet devices, which have enabled us to introduce effective mobile working.


ICJ has introduced mechanisms to share the stories of PABC and gather their views. This information is used to continually develop and improve the service. Customer surveys are used to capture feedback and inform service improvement. ICJ held a Stakeholder Event where over 100 representatives from across health and social care organisations and PABC came together to generate ideas on continuous improvement of ICJ.


Macmillan Cancer Support is using ICJ as a learning lab to replicate this model throughout the UK.


ICJ has delivered on all strategic objectives set out in the GCC Executive Committee report and the business plan, on time and under budget. Since the launch in February 2014, the impacts of ICJ has included:


  • 49% of carers identified are referred onto SWS for a formal assessment; the national average is 5%
  • On average clients report a 50% reduction in stress levels following their first HNA
  • 70% of responders to Client survey attribute the reduction in stress directly to ICJ
  • 97% of clients surveyed rated the ICJ service as excellent

We recognised that although we were receiving information from the NHS, we weren’t reaching everyone with a new cancer diagnosis. We approached this twofold; firstly we reached agreement with the NHS to provide information from the Cancer Tracker. We also developed a clinical engagement plan for acute and primary care to encourage health professionals to refer to ICJ. These measures have ensured we now reach all people in the city with a cancer diagnosis


A number of methods to review and monitor ICJ. These include:


  • Governance structures and steering group where progress and is reported regularly
  • Development plan where delivery against aims are constantly reviewed for further development
  • Facilitated Action Learning sets where staff and cancer experts review case studies for ongoing learning to develop ICJ
  • Patient Advisory group who challenge and contribute to the ongoing review and development of ICJ


Information from our new reporting system highlighted that the majority of visits were being carried out in peoples home.  In order to increase opportunities and patient choice we developed outreach services within community facilities including libraries and local pharmacies. This increased visits in the community from 10% to 41%. The impact is clients are engaging more with local community services and ICJ has increased capacity to deliver the ICJ to even more PABC.


We are currently developing an SVQ accredited training framework for all the link officers to undertake, which will provide a recognised standard and consistency of the skills and competencies of advisors.


The service user reference group has been instrumental in the development and improvement of ICJ. They reviewed and recommended changes to the ICJ invite letter and information leaflet. This had a direct impact on the improvement in uptake of the ICJ service. In addition, the group have identified further areas for development, including, Patient Transport and Palliative Care which the ICJ Programme Manager is taking forward.

Contact details:

To find out more about this case study, please contact:


Afton Hill

Policy Support Officer, Strategic Policy and Planning

Glasgow City Council

0141 287 0411

Case study added to site: June 2016

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