Delivering the Primary Care Network (PCN) service specification on early cancer diagnosis 2022/23

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Watch our PCN DES Video Mini-Series

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Please note these videos were produced in 2021/22 and the content is still relevant for 2022-23

Macmillan GP Cancer Lead, Dr Anthony Cunliffe, provides his top tips for tackling the PCN DES cancer early diagnosis 2021-22

CRUK GP Leads, Dr Jo Thomson and Dr Pawan Randev, discuss how Primary Care Networks can get started with work on cancer early diagnosis for the PCN DES 2021-22, and make suggestions for quality improvement activities to consider.

 

CRUK GP, Dr Neil Smith, shares his ideas on how Primary Care Networks can plan and build on cancer improvement activity to meet the requirements of the PCN DES 2021-22.

Macmillan GP, Dr Navdeep Alg, shares his suggestions of how practices and PCNs can better understand and tackle inequalities in cancer to fulfil requirements in the PCN DES 2021-22.

CRUK GP, Dr Ameesh Patel, talks about cancer safety netting requirements in the PCN DES 2021-22, including the new cancer safety netting SNOMED code, and what metrics PCNs could look at to inform activities.

Macmillan GPs, Dr Anthony Cunliffe and Dr Tania Anastasiadis, discuss digital and tech solutions that can support Primary Care Networks to meet requirements of the PCN DES on cancer early diagnosis 2021-22.

Review referral practice:

PCNs are required to review referral practice for suspected cancers and recurrent cancers, and work with their community of practice to identify and implement specific actions to improve referral practice, particularly among people from disadvantaged areas where early diagnosis rates are lower.

CRUK GP Dr Pawan Randev makes the following recommendations on how PCNs can support practices to improve their referral processes:

Understanding your data:
  Review your PCN level reports on Office of Health Improvement and Disparities (OHID) This will help you to benchmark your practices to understand any variation and to identify where improvements can be made for your PCN.
 

Review your tailored PCN report for the NCDA or any other PCN-wide audits to highlight existing good practice within the PCN, and help to identify any shared concerns or areas for PCN-wide targeted quality improvement. Using the data, encourage mutual learning and sharing of best practice, e.g. where one practice’s report shows they are doing well in an area that others within the PCN may be struggling with. 

Have a look at the e-RS referral data for your local area (updated monthly) to understand if referral levels locally are returning to pre-Covid levels and/or which cancer types are still challenged.

 

Improving the quality of referrals:
  Encourage your practices to take the free Gateway C module ‘Improving the Quality of Your Referral’ which focuses on clinical decision making and safety netting, what patients want to know when a referral is made, and what information that should be included in the referral to reduce avoidable delays at secondary care. Read about the module. Go to the module
  Access free CPD e-learning content to support you with the recognition and referral of suspected prostate cancers on Doctors.net. Complete the module here(link is external) or access a short message series here (link is external)(login required).
  Access CRUK ‘body’ infographic and interactive desk easel to support clinical decision making for suspected cancer.
  Encourage your practices to access the CRUK Safety Netting hub which includes a Summary Table, Flowchart, and Workbook and videos on how to use your clinical systems to embed safety netting. Facilitate discussion between your practices about their current safety netting processes and agree what best practice looks like and how you will collectively implement a consistent approach, including using the SNOMED codes for Safety Netting.
  Ensure all your practices are aware of and using the SNOMED code for safety netting. Click here for more details

 

 

 

Ensure patients receive high-quality information:
 

Have a look CRUK’s patient information about urgent referrals and promote CRUK’s Urgent Referral Explained leaflet  amongst your practices to help prepare patients for their referral and minimise DNAs. The leaflet is also available on accuRX for GPs to send a link directly to patients.  Some PCNs have added a step to their admin process to text this link after a referral is made: There may be other local resources to help – check locally.

 

CRUK GPs use software packages to support high quality information for patients and advice:

  • Consider backing up safety-netting advice via an AccuRx text such as “Please book another appointment if your cough hasn’t settled within 1 week of completing your course of antibiotics.”
  • Set up an AccuRx preset text for all 2WW referrals such as “You should receive an appointment at the hospital within 2 weeks (by x/x/xx), if you haven’t, please inform our reception team.”
  • Consider writing simple, specific management plans that you can copy and paste into an AccuRx text.
  Encourage your practices to use the CRUK’s Safety netting checklist for patient communication
  Encourage your practices to take the free Gateway C module ‘Improving the Quality of Your Referral’ which focuses on what patients want to know when a referral is made. Read about the module. Go to the module

Contribute to improving local uptake of National Cancer Screening Programmes

Contribute to improving local uptake of National Cancer Screening Programmes by working with local system partners – including the NHS England and NHS Improvement Regional Public Health Commissioning team and Cancer Alliance – to agree the PCN contribution to local efforts to improve uptake in cervical and bowel NHS Cancer Screening programmes and follow up on non-responders to invitations.

This must build on any existing actions across the PCN’s Core Network Practices and include at least one specific action to engage a group with low-participation locally.

CRUK GP Dr Neil Smith makes the following recommendations on how PCNs can support practices to improve their screening uptake:

Review your PCN level reports for screening uptake on the Office of Health Improvement and Disparities (OHID) .  This will help you to benchmark your practices to understand any variation and to identify where improvements can be made for your PCN.

The Office of Health Improvement and Disparities (OHID) have a dedicated section on their website about identifying and reducing inequalities(link is external) in screening programmes.

Practices may wish to look at particular groups of patients where there are inequalities in uptake and to focus their QI activity here. Download CRUK’s Reducing inequalities cancer screening guide(link is external)

The Office of Health Improvement and Disparities (OHID) have developed some animations to help understand the basics of screening and the different screening tests that men and women will be invited for throughout their lives, view them here(link is external)

Make sure your practices know about CRUK’s Bowel Screening Good Practice Guide (link is external) and the other valuable resources on the CRUK Bowel Cancer Screening Hub such as the CRUK video on ‘How to do the test’ and information about the FIT test.

Make sure your practices know about CRUK’s Cervical Screening Good Practice Guide (link is external) and look at the resources and evidence base on increasing cervical screening uptake.

Work with core network practices to adopt and embed FIT tests

Work with its Core Network Practices to adopt and embed the requesting of FIT tests where appropriate for patients being referred for suspected colorectal cancer;

This also will support PCNs to fulfil the Investment and Impact Fund (IIF) indicator (CAN-10):
Percentage of lower gastrointestinal two week wait (fast track) cancer referrals accompanied by a faecal immunochemical test result, with the result recorded either  in the seven days leading up to the referral, or in the fourteen days after the referral.

 

We encourage primary care networks to:

1. Develop a local data collection system to track how many lower GI referrals are happening with/without a FIT, and what happens to those referrals based on their FIT result.

To enable this, encourage your practices to:

  • Undertake an audit to assess the extent to which FIT tests are currently being used and to identify areas for improvement (i.e., return of tests, patient communication, supply)
  • Code and track all FIT tests (including repeat tests) and retain (or explicitly pass on) responsibility over initiated investigations until test results are returned, results are reviewed and acted upon appropriately
  • Have a system to document that all results have been viewed, acted upon appropriately and followed up
  • Ensure staff involved in logging results are aware of reasons for urgent tests and referrals

2. Engage with primary care staff (GPs and wider primary care teams) to raise awareness of FIT to enable effective implementation across your PCN:

To enable this:

  • Provide and signpost to the CRUK ‘How to do your FIT test’ resource to support patients to complete the test correctly, to reduce the number of rejected samples
  • Encourage Health Professionals to communicate to the patient the reasons for the test and importance of coming back if symptoms continue, get worse or new symptoms develop when waiting for the test results, a hospital appointment and even after a negative test result
  • Ensure Health Professionals are aware of the differences between the symptomatic and asymptomatic (screening) uses of FIT, so they can reinforce to patients that they still need to do the test in the event of symptoms, even if they’ve recently done one for screening. CRUK have created a Key differences in the use of FIT infographic to explain the differences
  • Educate the wider primary care teams on the use of FIT and how to have conversations with patients to complete the FIT test properly and return the test in a timely manner. Practices may find CRUK's web content on FIT symptomatic, including the latest information, safety netting advice and guidance useful.  See here

 

3. Implement PCN level systems to enable effective implementation and safety netting of FIT tests in the Lower GI pathway.

  • Advocate for clear local pathways and information about how tests and urgent referrals are recorded so primary care colleagues understand who is responsible for safety netting the patient when they are asked to complete a test
  • Encourage services to establish local service clarity on which patients are being held on which lists, with failsafe mechanisms to ensure patients are followed up
  • Encourage the clear communication of local pathways so primary care colleagues understand how to order FIT tests
  • Practice robust safety netting as a negative test result does not always rule out cancer. especially among patients with unresolved symptoms and it may still warrant further investigation depending on symptoms and clinical judgement
  • Encourage your practices to access the CRUK Safety Netting Hub which includes resources on how to use your clinical systems to embed safety netting

 

Work with core network practices to adopt and embed the use of teledermatology

Work with its Core Network Practices to adopt and embed where available and appropriate, the use of teledermatology to support skin cancer referrals (teledermatology is not mandatory for all referrals).

Encourage your practices to:

Refer to NICE Guidelines NG12 which includes the 7 point checklist to help with decision making when presented with symptoms associated with suspected skin cancer. 
Use dermoscopic images for referral via teledermatology services rather than directing patients to take their own images. Images must be of sufficient quality for the conclusive diagnosis of pigmented lesions and suspected melanoma. [1] Secure clinical image smartphone apps  (e.g. Consultant Connect® and Pando®) can aid clinical image capture in primary care.
Practice robust safety netting as some skin cancers may be missed. Encourage your practices to access the CRUK Safety Netting Hub which includes resources on how to use your clinical systems to embed safety netting.
Signpost to the NHSE ‘Dermatology Digital Playbook’  This resource provides support to clinical teams and organisations that are looking for digital tools to support the delivery of patient pathways.
Take advantage of Advice and Guidance channels/platforms where available to inform decision-making and assessment of cancer risk prior to referral. A range of skin cancer teledermatology pathways have been developed nationally with integration of the eRS advice and guidance system.

References

  1. NHSE Teledermatology Handbook

Increase proactive and opportunistic assessments

Focusing on prostate cancer and informed by data provided by the local Cancer Alliance, develop and implement a plan to increase the proactive and opportunistic assessment of patients for a potential cancer diagnosis in population cohorts where referral rates have not recovered to their pre-pandemic baseline.

Cancer Research UK do not advise men without symptoms to ask for the PSA test. This is because evidence shows that the PSA test offers no benefits for men without symptoms while putting men at risk of overdiagnosis – which can cause significant harm.
We also do not advise that men at higher risk of prostate cancer request a PSA test. This is because there is no clear evidence as to whether screening could be more helpful or more harmful than for average-risk men.
We do encourage people to speak to a health professional if they have any symptoms they are concerned about.

 

 

Encourage your pratices to:

Access NG12 summaries and visualisation tools such as the CRUK ‘body’ infographic(link is external) and interactive desk easel to support clinical decision making for suspected cancer.
Act on clinical suspicion with consideration of risk factors such as family history and black ethnicity. [1]
We encourage you to conduct face to face appointments/testing with patients if there is suspicion.
 Take advantage of Advice and Guidance channels/platforms
Practice robust safety netting as some cancers can be missed. Encourage your practices to access the CRUK Safety Netting Hub which includes resources on how to use your clinical systems to embed safety netting

References

  1. Carney M, Quiroga M et al. Effect of pre-existing conditions on bladder cancer stage at diagnosis: a cohort study using electronic primary care records in the UK. Br J Gen Pract 2020;70:e629-e635

Review use of non-specific symptoms pathways

Review use of their non-specific symptoms’ pathways, identifying opportunities and taking appropriate actions to increase referral activity

Have a look at our latest cancer insight: Managing non-specific symptoms of cancer and safety netting.

GP perspective videos:

Dr Anant Sachdev, Cancer Research UK GP highlights in this video, the importance of routinely using suspected cancer referral guidelines despite current complexities around the management of cancer referrals.

Dr Neil Smith, Cancer Research UK GP highlights in this video, key considerations when managing people who present with non-specific symptoms.

Considerations for managing patients with non-specific symptoms

Access NG12 summaries and visualisation tools such as the CRUK ‘body’ infographic and interactive desk easel to support clinical decision making for suspected cancer.
Urgently refer people at a positive predictive value threshold of 3% or higher and at an even lower threshold for children, young people and for primary care tests.
Use primary care investigations where available at point of care, to triage and manage the appropriate routes to send people. Chest X-rays, CT scans and blood tests are usually easily accessible and can help speed up cancer diagnosis.
Don’t be reassured by negative test results. Chest X-Rays, PSA and CA125 blood tests have false negative rates of 15-25%.
Take advantage of Advice and Guidance to inform decision-making and assessment of suspicion of cancer prior to referral.
Implement robust and consistent safety netting to help manage diagnostic uncertainty. Safety netting is vital for all patients, whether they’re being referred for tests, or specialist advice or not and recorded on the clinical system.
Use non-specific symptom pathways ( previously known as Rapid Diagnostic Centres (RDCs)), if available, which provide alternative routes for patients when GPs are unsure which site-specific route would be appropriate.
Remember to act on clinical suspicion if you still have concerns.

 

Monitoring performance and benchmarking

A PCN dashboard was launched in 2021 and includes key metrics to allow every PCN to see the benefits it is achieving for its local community and patients. It is intended to support local quality improvement, enabling benchmarking between practices within PCNs, and between comparable PCNs.

In line with the PCN requirements, practices of a PCN must use the relevant SNOMED code for Safety Netting. Only those codes included in the supporting Business Rules will be acceptable to allow CQRS calculations. A PCN’s Core Network Practices will therefore need to ensure that they use the relevant codes and if necessary, re-code patients. 

Ensure you use the new SNOMED code for: Delivery of safety netting for patients on urgent referral pathway for suspected cancer. You can search for this by putting in ‘cancer safety netting’ into your code browser and will find the code 1239431000000107.

However, to make the best use of this, we would advise using safety netting templates which incorporate this SNOMED code and allow you to tick the relevant section on the templates, as well as set a date for any reminders.

Have a look at your PCN’s use of the official Snomed codes for Safety Netting compared to other PCNs, using the PCN dashboard.

Learning from others

  • Learn how Coventry Sowe PCNs (North and South) have started working on the early diagnosis of cancer PCN specification – download case study.

  • Learn how Suffolk PCNs have worked together to deliver additional cervical screening capacity – download case study.

  • Looking for ideas? Be inspired by other good practice case studies - examples of good practice for delivering PCNs

  • Learn how Suffolk PCNs have worked together to deliver additional cervical screening capacity. You can read more about the set up here and the full case study here