How to do the audit

Man at computer

Get involved

Wales register here

(NHS internet connection and firewall will be required)

How the audit will work in practice, the time commitment involved, when the audit data collection period is, who from the practice can get involved, and the support available to practices during and after the audit.

Collecting the data

Collecting data on a single patient took approximately 15 minutes during the pilot study. But this depends on patient complexity, clinical system navigation ease and internal support availability, so time for data entry could be longer for some patients. Each GP can expect around 8 cancer diagnoses, making the average time commitment around two hours per GP, but this may vary. Practices with multiple GPs need to factor in approximately 8 patients per GP at the practice.

The data collection period will last for several months. You can input data on all patients at once or in multiple instalments and submit once.

It is up to each practice how they decide to take part in the audit – whether all GPs review their own patients, whether they review each other’s’, or whether one GP leads on this on behalf of the others.

GPs registrars and medical students may complete the audit on behalf of the practice. The supervising GP will need to oversee and quality assure their work in order to ensure accurate data extraction and to maximise any practice learning opportunities during and following the audit. Anyone accessing the data from the cancer registries will need to satisfy the verification process requirements.

If a practice wishes to delegate the data collection to a non-clinical colleague, they will need to be satisfied that the individual concerned has good knowledge of medical terminology and is sufficiently trained to review clinical notes. There are some areas of the audit where we have specified that only a GP can respond (where clinical judgment is required).

We are asking practices to undertake the data collection on all patients registered to the practices that were diagnosed in 2014 regardless of potential use of private diagnostic care or treatment and regardless of referral or diagnostic route.

Non-melanoma skin cancer and non-malignant tumours (ICD-10 C44) will be excluded from the patient list returned to GPs.

In England and Wales, patients are identified by the English registry (NCRAS) or Welsh registry, respectively, and made available to the GP practice via an online portal. In Scotland, patients will be identified by the Scottish registry (NHS National Services Scotland) and transferred to the practice.

Patients whose cancer is recorded by the cancer registry as being detected via one of the national screening programmes (breast, cervical and bowel) will be present in your list of patients, but you will not need to complete primary care data for these patients.

There may be a small number of cases, mainly bowel and possibly cervical, where the cancer registry does not have a record of the cancer being screen detected. Where you know this, please contest the registry data and say the cancer was detected via screening, and complete all other data fields as ‘not applicable’.

Practices will have several months to complete the data collection:

  • England: September - February 2017
  • Scotland: January - May 2017
  • Wales: TBC

GPs will need access to their clinical system to complete the audit, and they will need to comply with their Information Governance good practice requirements. GPs in England and Wales will need to complete the audit in a location that has a secure N3 internet connection (connected to the NHS internet, behind the NHS firewall) to satisfy Public Health England’s data security requirements.

The data specification was informed by that of the 2009/10 National Audit of Cancer Diagnosis in Primary Care*, updated where needed. Furthermore, a pilot was undertaken to shape the data collection processes. While creating the final data collection system user testing was completed, to make sure that this data collection is as easy for practices as possible.

*http://www.rcgp.org.uk/policy/rcgp-policy-areas/national-audit-of-cancer

GPs in England and Wales taking part in the audit will need access to their own clinical system, and be able to access the data collection portal through a N3 internet connection (connected to the NHS internet, behind the NHS firewall).

GPs and practice staff will need to access an nhs.net or wales.nhs.uk email in order to register and successfully complete the GP verification processes. Computers must have an internet browser of Internet Explorer 8 or above to access the online portal.

In Scotland GPs taking part in the audit will need access to their own clinical system and access to their own nhs.net email address.

We are seeking information on:

Patient characteristics; ethnicity, communication difficulties, living arrangement, language competency, housebound status and co-morbidities. Symptoms, test results and investigations ordered. Date of referral, type of referral and number of referrals. Avoidable delays in patient pathway. Place and date of first presentation, number of consultations, safety netting, the date a patient was seen by specialist and the data a patient was told they had cancer.

In England and Wales, data will be collected via a specifically designed data collection system (the NCDA portal).

This is a short video of the online data collection portal that demonstrates how easy it is to use.

In Scotland, data will be collected on Excel spreadsheets sent to the practce by ISD Scotland.

English and Welsh practices can register via this website or via https://nww.canceraudit.phe.nhs.uk. In the first instance a GP needs to register so they can be verified to protect the patient identifiable data. Once the GP has logged into the portal, the GP can add other users at the practice. Each other user will be sent their own login details and will see the same practice list of patients.

Once a GP has registered the emails they receive from the portal will take them step by step through what they have to do. First they will confirm their email address, they will then be told that their details are being verified and that login details will be sent to them shortly.

Once the first GP has logged in, they will be able to add other users (other GPs, clinical or non clinical staff) within the practice who will all be sent separate log in details. Other users will be able to then login independently, view all the patients and collect and input the audit data into the portal.

In England and Wales please email phe.clinicalaudit@nhs.net and include the NHS number of the patient.

In Scotland please email nss.isdncda@nhs.net and include the ISD Reference number from the top of the form (not the CHI number).

Audit outputs

Completing the audit allows practices to reflect on their clinical practice and practice based systems and processes. Specific insights may include:

  • Types of delay
  • Where delays occur
  • Factors contributing to multiple consultations
  • Impact of patient characteristics
  • Overview of presenting symptoms by key tumour types to highlight complexities
  • Presenting symptoms by place of presentation
  • Identification of good practice 

In England, feedback will be available at practice and CCG level (in CCGs where sufficient practices take part), as well as national. In Scotland the feedback will be available at practice and Health Board level, as well as national. In Wales, feedback will be available at practice level and as a summary report.
 

Potential case by case feedback

In England and Wales the data collection portal will aim to flag:

  • Patients who have an emergency diagnosis referral type
  • Patients who died in under 30 days after their diagnosis date
  • Patients with screenable cancers (and age group) who were diagnosed at late stage
  • Breast cancer, female, aged 50-70 years old
  • Bowel cancer, aged 60-74 years old in England, Wales and Northern Ireland, 50-74 years old in Scotland
  • Cervical cancer, female, aged 25-64 years old in England, Wales and Northern Ireland, 20-60 years old in Scotland
  • Patients with cancer that did not undergo any GP investigations but had 3+ consultations prior to referral

 

Comparison against national average

In England and Scotland this will compare practice averages to the national average and show the difference from the average (similar to GP profiles, difference will be reported as high/low/not significantly different).

  • Time from presentation to diagnosis
  • Number of pre-referral consultations with GP
  • The number of primary care made referrals per patient before diagnosis
  • The number of primary care led investigations per patient before diagnosis
  • What proportion of patients were referred on the urgent referral pathway
  • What proportion of patients over 60 were referred on the urgent referral pathway
  • What proportion of patients diagnosed with lung, prostate and ovarian cancer had a chest X-ray, PSA level or CA125 level (as appropriate) undertaken in primary care after their first presentation and before diagnosis

Information on their area

  • How many member practices participated
  • What size population the findings covered

 

Comparison against national average

Data will then be fed back to CCGs as an average across the CCG, to be compared to national average and suggested standards. The feedback will only be given to a CCG if an adequate number of practices participate with required data quality. CCGs with low numbers of participating practices will not receive this feedback. 

  • Time from presentation to diagnosis
  • Number of pre referral consultations with GP, broken down by tumour site (combining rare cancers)
  • The number of primary care made referrals per patient before diagnosis, broken down by tumour site (combining rare cancers)
  • The number of primary care led investigations per patient before diagnosis, broken down by tumour site (combining rare cancers)
  • What proportion of patients diagnosed with lung, prostate or ovarian cancer had a chest X-ray, PSA level or CA125 level (as appropriate) undertaken in primary care after their first presentation and before diagnosis.

Information on their area

  • How many member practices participated
  • What size population the findings covered

 

Comparison against national average

Data will then be feedback to health boards as an average across the health board, to be compared to national average and suggested standards. The feedback will only be given to a health board if an adequate number of practices participate with required data quality. Health boards with low numbers of participating practices will not receive this feedback. 

  • Time from presentation to diagnosis
  • Number of pre referral consultations with GP, broken down by tumour site (combining rare cancers)
  • The number of primary care made referrals per patient before diagnosis, broken down by tumour site (combining rare cancers)
  • The number of primary care led investigations per patient before diagnosis, broken down by tumour site(combining rare cancers)
  • What proportion of patients diagnosed with lung, prostate or ovarian cancer had a chest X-ray, PSA level or CA125 level (as appropriate) undertaken in primary care after their first presentation and before diagnosis

Section 1: Dataset characterisation
1.1    Characterise reported disagreements in data between registration data and primary care
1.2    For each field tabulate the fraction data items complete; missing; and invalid (if relevant)
1.3    Compare final tumour/patient cohort to full 2014 cancer registration cohort
1.3.1    Variation by sex; age ; cancer type; stage; survival time

Section 2: Interval length & consultations
2.1    Interval lengths (presentation to referral; referral to specialist visit; total) variation by:
2.1.1    sex; age ; cancer type; stage; survival time; 
2.1.2    language; communication; housebound status and other patient factors
2.1.3    symptom
2.1.4    investigations
2.1.5    referral type; multiple  referrals; referral speciality 

2.2    Consultations (number and type of consultations) by:
2.2.1    sex; age ; cancer type; stage; survival time
2.2.2    language; communication; housebound status and other patient factors
2.2.3    symptom
2.2.4    investigations
2.2.5    referral type; multiple  referrals; referral speciality 

Section 3: Investigation prior to referral
3.1    Characterise investigations including variation by:
3.1.1    sex; age ; cancer type; stage; survival time
3.1.2    language; communication; housebound status and other patient factors
3.1.3    consultations
3.1.4    symptom
3.1.5    referral type; multiple  referrals; referral speciality 

Section 4: Comparison of referral pathway
4.1    Characterise referral type (including multiple referrals and speciality) by:
4.1.1    sex; age ; cancer type; stage; survival time
4.1.2    language; communication; housebound status and other patient factors
4.1.3    consultations
4.1.4    symptom
4.1.5    investigations

4.2    Compare referral type as recorded by GP to that recorded centrally and tabulate difference by:
4.2.1    referral type; multiple  referrals; referral speciality 
4.2.2    sex; age ; cancer type; stage; survival time
4.2.3    language; communication; housebound status and other patient factors
4.2.4    consultations
4.2.5    symptom
4.2.6    investigations

Patient consent and information security

Financial support for audit in England

In January, the audit had 573 practices verified and was able to collect data on over 26,000 patients. Only a quarter of these practices had actually gone on to complete their patient data (just over 11,000). While the individual practice learning for those practices was possible, the national picture/baseline was unlikely to be able to draw any statistically valid conclusions, especially for rarer cancers. With this in mind, and as a delivery partner of the audit, NHS England found financial support for verified practices to complete all their patients and increase the amount of data available, making the national analysis far more meaningful.  

Practices were included in the scheme if they:

  • Had already completed the audit for 95% or more of their patients
  • Completed the audit for 95% or more of their patients between 6th of January and 17th of February

Practices were excluded from the scheme if they:

  • Were already funded by their CCG (unless less than £10 per patient in which case a top up payment may be arrange via their CCG)
  • Were already funded by their SCN (unless less than £10 per patient in which case a top up payment may be arrange via their CCG)
  • Did not complete the audit for at least 95% of their patients

There are a number of reasons a practice might think they are/might not be able to audit all the patients in their list and these are listed below. The practice will be paid if they have audited at least 95% of the patients they can, the fact they may not have been able to audit all the patients will be considered. What the practice should do/ the outcomes are below:

The patient was not registered with the practice at time of diagnosis

The practice should use the button ‘Flag patients not registered at practice’ on the portal to flag these patients and remove them from their list. Removing them from the list means they are no longer used in the denominator for the 95% calculation.

The patient is no longer registered with the practice

In these cases the patient notes should still be accessible and we want these patients included in the audit.

The patient is deceased and they can’t access the notes

The practice should be able to access deceased patient notes, and we very much want these patients included in the audit as they may be the ones with very valuable learning. Obviously there may be times this is just not possible, so the practice should email the audit inbox PHE.ClinicalAudit@nhs.net and inform them of the patients who can’t be audited, so they can be removed from the 95% calculation.

The practice are querying the diagnosis with the cancer registry

The practice should email the audit inbox PHE.ClinicalAudit@nhs.net with any queries of this nature as they will go straight to the cancer registry for them to investigate. During this investigation and until resolved they will not be used in the 95% calculation. 

We mean a practice will get paid £10 per audited patient diagnosis, not £10 per registered population.

At the end of the data collection period (17th February) the audit team exported the data, practices did not need to do anything and there is no need to claim the money. The percentage completion for each practice was calculated and adjustments were made where practices had queried patients with PHE. NHS England was told which practices to pay, how much to pay them and which CCG they are in.

In areas with no CCG incentive funding, payments will be made automatically to practices' accounts via NHS England. We anticipate this will be on the usual Exeter contract payment date in April. Practices will therefore need to accrue for this income, although some practices may receive their payment on their March Exeter payment date. The Exeter pay code detail will be included in the remittance and the reference will be ‘Cancer Programme Audit Revenue Fund’.

In areas with CCG incentive funding schemes, arrangements may be different. Practices in these areas will be informed of how payment processes will work in their area.

Unfortunately these practices are not eligible for funding unless they completed the remaining patients, as they needed to complete 95% of their patients or more to be funded. If they chose not to complete the remaining patients (diagnosed July-December), their data will still be utilised in the national audit and they will still receive practice feedback as discussed. 

We don’t want practices to be paid twice, so there are a number of scenarios with outcomes all listed below:

A CCG incentivised exactly £10 per audited patient (exactly the same amount of money as NHS England are offering)

In this case the CCG will keep all the money given to them by NHS England, so the CCG will be repaid the money they spent.

A CCG incentivised more than £10 per audited patient

In this case the CCG will keep all the money given to them by NHS England, which they can use to offset some of the money they have spent.

A CCG incentivised less than £10 per audited patient

In this case the CCG will pay the practices the difference. For example if the CCG paid a practice £5 per audited patient, they will pay a further £5 from the NHS England funding, so making the total paid to practices £10 per audited patient. The CCG will have been repaid the money spent and the practices received the same total financial support as all others. 

The timelines moved back slightly to reflect this deadline extension.

Activity

England

Scotland

Data cleansing/analysis

Feb-Mar 2017

July-Aug 2017

Local data analysis

Mar-July 2017

Sept- Oct 2017

National report published

August 2017

Novr 2017

Local feedback starts

May 2017

Oct 2017

Contact us

Email the team for more information or any queries.

Email us

Last reviewed

GPs from England, Scotland and Northern Ireland who are interested in getting involved in future audits should contact the team

Email us

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