Working on the QOF Quality Improvement module on early cancer diagnosis

Coronavirus (COVID-19)

We have created a central resources hub for Health Professionals which hosts all of our CRUK resources and further materials to help with managing the pandemic. We are updating the information as guidance changes. There is also a page specifically for patients on our about cancer hub.

Health Professional COVID-19 and Cancer Hub

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Cancer Research UK Facilitator’s can help deliver your requirements

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The aim of the revised QOF QI domain is to contribute to the restoration of screening services with a focus on cervical screening, and to ensure patients who require urgent referral are identified, supported and managed.  

This information focuses on the both the revised requirements for 2020/21 and the original guidance.

See the QOF QI changes for 2020-21 in light of Covid or See the QOF QI guidance for 2020-21(link is external)

These GP contract webpages and the recommendations have been developed with our team of CRUK GPs. The CRUK GPs are all practising GPs, as well as being involved in more strategic work across their respective Cancer Alliances.

Revised QOF QI requirements

Restoring cervical screening uptake to pre-Covid levels

Practices should continue to focus on restoring the cervical screening programme among their registered population: 

  • Ensure appointments are offered to women who are eligible and due to be screened 
  • Actively identify women who have had their cervical screening appointment delayed or cancelled due to COVID-19 and ensure that they are offered an appointment.  
    • NHS England and NHS Improvement have produced guidance on prioritisation of patients for screening.
    • This may be via a review of local records or final non-responder lists
  • Continue with innovative service developments implemented as part of the pandemic response that have supported improved equitable access
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  • Be alert to people who have missed out on their screening appointment:  
    • those who had their invitation delayed.
    • those who were scheduled for screening, but their appointment could not go ahead
    • those who were eligible for screening but did not attend
    • those who were screened and received a positive result, however they are awaiting further tests or did not want to attend for further tests due to concerns about COVID-19
  • Consider running a separate screening clinic to provide more capacity
  • Increasing accessibility, for example by arranging screening clinics at the weekend or during evenings, may address barriers to participation for some
  • Inform patients about what to expect if they do attend. Assure patients what safety measures are in place and how their experience might differ to usual
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For other useful tips and resources, download the CRUK useful tips for how, in your practice, you can support people to access cancer screening services during Covid recovery.
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Download CRUK’s Cervical Screening Good Practice Guide (UK-wide) and look at evidence based interventions for increasing uptake in the CRUK cervical screening hub. Download CRUK's Cancer Insight on cervical screening and make sure your practices see a copy
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Review your practice profile on PHE Fingertips(link is external). This will help you to benchmark your practice to understand any variation in screening uptake and to identify where improvements can be made. CRUK has prepared a short navigation video(link is external) guide to help you.

Dr Debbie Harvey, CRUK GP recommends the following top tips:

  1. Make sure you check what is taking place (or being planned) locally before you embark on your own planning and actions, so you don’t reinvent the wheel
  2. There may be specific cancer working groups which bring together relevant stakeholders that you could tap into
  3. Support will be available from a range of organisations including your local CCG, who can help co-ordinate activities, to avoid working in silos
  4. Make sure you link in with your local Cancer Alliance and public health teams who will likely have local plans and resources to support you.
  5. Your area may already have a CRUK Facilitator, CRUK GP, Macmillan GP or other cancer lead who will be aware of specific work around cancer which might support you and avoid unnecessary effort and duplication
  6. CRUK is well placed to help practices/PCNs, and it should be noted that CRUK is an integral part of the support system for GPs and PCNs

Building public confidence that general practice and other healthcare settings can be accessed safely

Practices should proactively engage with patients, families and carers to build confidence in primary care: 

  • Take action to offer reassurance that general practice and other healthcare settings (including screening) can be accessed safely 
  • Address inequalities and focus on those groups who may experience barriers to accessing services and in which there might be a disproportionate drop in activity: 
    • Send a text message or a letter, in various inclusive formats – easy read, plain English and translations to all patients to provide reassurance about accessing general practice.
    • Work with local partners to include targeted and culturally competent messages in community newsletters and local media. 
    • Ensure that all patients receive a consistent message that general practice is open and available to support them.
    • Implement this at a PCN level and work with local people, community and faith-based organisations and networks to help understand how best to engage with the diverse needs of their local population;
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Find out what local awareness campaigns are running and what resources might be available for you to adopt.
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Watch the Cancer Research UK 30 second video encouraging people to get in touch with their GP without delay if they have a symptom that they’re concerned about or have noticed a change that is unusual for them.
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Download the CRUK briefing note for health professionals to encourage patients to seek help
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Consider adding the key messages listed in the briefing note to your practice website or communicating these via text message to your patients

Dr Debbie Harvey, CRUK GP recommends the following top tips:

  1. Make sure you check what is taking place (or being planned) locally before you embark on your own planning and actions, so you don’t reinvent the wheel
  2. There may be specific cancer working groups which bring together relevant stakeholders that you could tap into
  3. Support will be available from a range of organisations including your local CCG, who can help co-ordinate activities, to avoid working in silos
  4. Make sure you link in with your local Cancer Alliance and public health teams who will likely have local plans and resources to support you.
  5. Your area may already have a CRUK Facilitator, CRUK GP, Macmillan GP or other cancer lead who will be aware of specific work around cancer which might support you and avoid unnecessary effort and duplication
  6. CRUK is well placed to help practices/PCNs, and it should be noted that CRUK is an integral part of the support system for GPs and PCNs

Infographic showing the QOF

Returning referrals to pre-Covid levels, improving the quality of referrals; and awareness of referral and testing pathways

Practices should monitor their suspected cancer referral rates and assess if these are returning to their previous levels seen before COVID-19. Practices are encouraged to reflect and identify where they could improve on:  

  • The quality of referrals, including how far implementation aligns with NG12 guidance and seeking to support a return to pre-pandemic levels of referral rates;  
  • Awareness of referral and testing pathways, including the impact of any pathway changes implemented as part of the pandemic response;  

Practices should consider using learning event analysis (LEA) to support these actions, and share learning via practice and PCN meetings. Practices may wish to focus LEA activity on areas that have been significantly impacted by the pandemic, for example lung and colorectal referral pathways, or where patients have been diagnosed at stage 3 or 4.

Have a look at the e-RS referral data for your CCG (updated monthly) to understand if referral levels locally are returning to pre-Covid levels and/or which cancer types are still challenged.
Download the CRUK guide on recognition and referral of suspected lung cancer during the COVID-19 pandemic which highlights some of the key messages for health professionals, particularly GPs, aiming to reinforce the importance of being alert to the risk of lung cancer in patients, and has gone out across the UK.
Familiarise yourself with the Lung Clinical Expert Group guide to the Differentiation of the Cs in lung cancer: Cancer vs. COVID
Consider undertaking Learning Event Analysis for any lung or colorectal cancer diagnoses during Covid.
Familiarise yourself with any new local FIT pathways for patients who meet criteria for urgent suspected cancer referral (‘high risk’). These have been introduced during Covid-19, with a view to helping to prioritise the limited endoscopic capacity to those most in need. Read the national guidance here.
Access GatewayC’s resources on suspected cancer referrals during Covid. There is a useful range of free webinars, and short Covid-related updates.
Review your practice profile on PHE Fingertips(link is external).  This will help you to benchmark your practice to understand any variation in referral practice and to identify where improvements can be made. CRUK has prepared a short navigation video(link is external) guide to help you.
Access NG12 summaries and visualisation tools such as the Cancer Maps(link is external)CRUK ‘body’ infographic and interactive desk easel and Macmillan Top Tips

Dr Debbie Harvey, CRUK GP recommends the following top tips:

  1. Make sure you check what is taking place (or being planned) locally before you embark on your own planning and actions, so you don’t reinvent the wheel
  2. There may be specific cancer working groups which bring together relevant stakeholders that you could tap into
  3. Support will be available from a range of organisations including your local CCG, who can help co-ordinate activities, to avoid working in silos
  4. Make sure you link in with your local Cancer Alliance and public health teams who will likely have local plans and resources to support you.
  5. Your area may already have a CRUK Facilitator, CRUK GP, Macmillan GP or other cancer lead who will be aware of specific work around cancer which might support you and avoid unnecessary effort and duplication
  6. CRUK is well placed to help practices/PCNs, and it should be noted that CRUK is an integral part of the support system for GPs and PCNs

Having robust and consistent systems in place for safety netting

Practices should ensure they have a robust and consistent system in place for safety netting supported by high-quality, appropriate and responsive communication and patient information, for patients who:  

  • Have been placed on an urgent referral pathway for suspected cancer, including proactive follow-up of those who do not attend any appointments;  
  • Have not been referred due to the level of risk and or/patient concern;  
  • Have been referred on an urgent referral pathway but have been downgraded with the consent of the primary care professional.  

This should include practices understanding the status of patients who are/have been safety netted during the pandemic period, and if further action may be required.  

Practices should consider using learning event analysis (LEA) to support these actions, and share learning via practice and PCN meetings. Practices may wish to focus LEA activity on areas that have been significantly impacted by the pandemic, for example lung and colorectal referral pathways, or where patients have been diagnosed at stage 3 or 4.

Notepad Icon COVID-19 has reinforced the importance of safety netting. Download our Safety Netting during Covid recovery document which includes key safety netting tips, organised around some of the patient scenarios that the pandemic has brought to the fore.  
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Ensure you use 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.

RCGP logo Consider undertaking Learning Event Analysis for any lung of colorectal cancer diagnoses during Covid.
Computer mouse icon Encourage your practices to access the CRUK Safety Netting hub where you can find a workbook and self assessment checklist, as well as information about best practice and a useful infographic. 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 Snomed codes when available later in 2020
Film camera icon If you use SystmOne, watch this short video(link is external) by CRUK GP Pawan Randev from the East Midlands which demonstrates how to incorporate safety netting into your GP clinical system. GPs may find it useful when considering safety netting patients referred on a 2ww referral. This video covers just one aspect of the safety netting management strategy for patients, tests and referrals used in the context of diagnostic uncertainty in healthcare.  It aims to ensure patients are monitored until signs and symptoms are explained or resolved.
Film camera icon Alternatively, signpost any practices using EMIS Web to the electronic safety netting toolkit for cancer. This uses template/forms to schedule diary reminders in the clinical system and reminds/alerts practice staff to follow up at a later date. To support GP practices implement the toolkit, there is a video guide(link is external), a user guide(link is external) and an admin user guide.

Dr Debbie Harvey, CRUK GP recommends the following top tips:

  1. Make sure you check what is taking place (or being planned) locally before you embark on your own planning and actions, so you don’t reinvent the wheel
  2. There may be specific cancer working groups which bring together relevant stakeholders that you could tap into
  3. Support will be available from a range of organisations including your local CCG, who can help co-ordinate activities, to avoid working in silos
  4. Make sure you link in with your local Cancer Alliance and public health teams who will likely have local plans and resources to support you.
  5. Your area may already have a CRUK Facilitator, CRUK GP, Macmillan GP or other cancer lead who will be aware of specific work around cancer which might support you and avoid unnecessary effort and duplication
  6. CRUK is well placed to help practices/PCNs, and it should be noted that CRUK is an integral part of the support system for GPs and PCNs

Original QOF QI requirements

Identifying areas for improvement

Practices will need to:

  • Assess their practice screening programme uptake rates compared to local or national baselines. Practices may wish to focus upon inequalities in screening, particularly for those at risk and with low uptake
  • Assess their current referral practice through:
    • Participation in the National Cancer Diagnosis Audit or other retrospective audit of recent cancer diagnoses
    • From the audit, undertake a more in-depth learning / significant event analysis around a patient where the referral or diagnosis process could have been better
  • Practices could also, or alternatively, audit and review the current system in place for safety netting around suspected cancer diagnoses as their early diagnosis activity

CRUK GP Dr Tina George makes the following recommendations:

Screening:
 

Review your practice profile on PHE Fingertips. This will help you to benchmark your practice to understand any variation in screening uptake and to identify where improvements can be made. CRUK has prepared a short navigation video guide to help you.

 

Access the CRUK tool which compares a practice's bowel screening coverage to what’s expected considering the characteristics of practice population. This tool currently uses 2017-18 data but will be updated for 2018-19 shortly. If you have queries about the tool, email stats.team@cancer.org.uk

 

Use the Macmillan Toolkit for ready-to-use searches (suitable for practices using EMIS, SystmOne or INPS Vision) to identify any non-responders

 

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 in bowel cancer screening guide

 

Consider the following actions:

 

Download CRUK's Bowel Screening Good Practice Guide and look at the CRUK bowel screening hub as an invaluable one-stop hub of evidence based information, case studies and further information about informed choice as screening can have both benefits and harms. Download CRUK's Cancer Insight on bowel screening and make sure your practices see a copy

 

Download CRUK’s Cervical Screening Good Practice Guide (UK-wide) and look at evidence based interventions for increasing uptake in the CRUK cervical screening hub. Download CRUK's Cancer Insight on cervical screening and make sure your practices see a copy

 

Referrals and safety netting:
 

Review your practice profile on PHE Fingertips.  This will help you to benchmark your practice to understand any variation in referral practice and to identify where improvements can be made. CRUK has prepared a short navigation video guide to help you.

 

 

If you took part in the 2019 National Cancer Diagnosis Audit, take a look at your NCDA report to help understand how patients were diagnose with cancer at your practice to plan targeted QI. If not, have a look at the audit on the RCGP webpages which is similar to the NCDA.

 

Access NG12 summaries and visualisation tools such as the Cancer MapsCRUK ‘body’ infographic and interactive desk easel and Macmillan Top Tips

 

Encourage your practices to access the CRUK Safety Netting hub where you can find a workbook and self assessment checklist, as well as information about best practice and a useful infographic. 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 Snomed codes when available later in 2020

 

If you use SystmOne, watch this short video by CRUK GP Pawan Randev from the East Midlands which demonstrates how to incorporate safety netting into your GP clinical system. GPs may find it useful when considering safety netting patients referred on a 2ww referral. This video covers just one aspect of the safety netting management strategy for patients, tests and referrals used in the context of diagnostic uncertainty in healthcare.  It aims to ensure patients are monitored until signs and symptoms are explained or resolved.

 

 

Alternatively, signpost any practices using EMIS Web to the electronic safety netting toolkit for cancer. This uses template/forms to schedule diary reminders in the clinical system and reminds/alerts practice staff to follow up at a later date.

To support GP practices implement the toolkit, there is a video guide, a user guide and an admin user guide.

 

Download CRUK's Cancer Insight on Safety Netting and make sure your practices see a copy

 

General
 

Encourage your practice to undertake CPD activities relating to the early diagnosis of cancer. CRUK has a range of face to face, on-line and e-learning opportunities 

 

Enquire about free tailored support from your local CRUK Facilitator. They can help you to identify interventions to improve screening uptake tailored to the needs of your practice population. Interventions which have been found to consistently support improvements in bowel screening uptake have been reported as: 

  • pre-screening reminders 
  • GP endorsement
  • more personalised reminders for non-participants
  • more acceptable screening tests

Dr Debbie Harvey, CRUK GP recommends the following top tips:

  1. Make sure you check what is taking place (or being planned) locally before you embark on your own planning and actions, so you don’t reinvent the wheel
  2. There may be specific cancer working groups which bring together relevant stakeholders that you could tap into
  3. Support will be available from a range of organisations including your local CCG, who can help co-ordinate activities, to avoid working in silos
  4. Make sure you link in with your local Cancer Alliance and public health teams who will likely have local plans and resources to support you.
  5. Your area may already have a CRUK Facilitator, CRUK GP, Macmillan GP or other cancer lead who will be aware of specific work around cancer which might support you and avoid unnecessary effort and duplication
  6. CRUK is well placed to help practices/PCNs, and it should be noted that CRUK is an integral part of the support system for GPs and PCNs

Creating an improvement plan

Practices should focus their QI activities on delivering improvement across the following measures:

  • An increase in the follow-up and informed consent/refusal of screening for bowel cancer, or other screening programme (as appropriate)
  • A reduction in inequitable uptake of screening in population groups
  • An increase in the proportion of cases where cancer diagnoses are reviewed and learnt from.
  • An increase in the proportion of suspected cancer referrals where a demonstrably robust practice-wide system for safety-netting is used.
  • A decrease in the time from presentation to referral

CRUK GP Dr Anant Sachdev makes the following recommendations for choosing quality improvement activities:

Use the Quality Improvement Toolkit for Early Diagnosis of Cancer to support practice teams to improve their early diagnosis of cancer by helping them to understand and improve referral processes

Watch the five, short early diagnosis of cancer QI screencasts developed by CRUK and RCGP which aim to help GPs use evidence-based QI methods to understand their baseline, explore issues, plan QI and measure its impact

Access the RCGP ‘QI Ready’ cancer early diagnosis case studies specifically developed by CRUK with GP practices that participated in previous rounds of NCDA and then undertook QI activity. These offer a useful set of ‘prompts’ for practices to consider in terms of what QI activities might be appropriate for them, including one on safety netting; one on increasing screening uptake and one on improving cancer referrals

 

Enquire about free tailored QI support from your local CRUK Facilitator

Dr Debbie Harvey, CRUK GP recommends the following top tips:

  1. Make sure you check what is taking place (or being planned) locally before you embark on your own planning and actions, so you don’t reinvent the wheel
  2. There may be specific cancer working groups which bring together relevant stakeholders that you could tap into
  3. Support will be available from a range of organisations including your local CCG, who can help co-ordinate activities, to avoid working in silos
  4. Make sure you link in with your local Cancer Alliance and public health teams who will likely have local plans and resources to support you.
  5. Your area may already have a CRUK Facilitator, CRUK GP, Macmillan GP or other cancer lead who will be aware of specific work around cancer which might support you and avoid unnecessary effort and duplication
  6. CRUK is well placed to help practices/PCNs, and it should be noted that CRUK is an integral part of the support system for GPs and PCNs

Implementing the plan:

Practices should implement the improvement plan they have developed, involving the whole practice team and engaging with external colleagues, for example public health and the screening service secondary care or other local practices.

Where possible, patients should be involved in quality improvement activity, eg through discussion with the practice’s patient participation group, surveys and or focus groups.

GP network peer review meetings

Practices will need to take part in a minimum of two GP network peer review meetings to enable shared learning across the network. The first meeting should aim to validate and agree meaningful QI activity plans and to share baseline information. The second should focus on shared learning from the quality improvement process and change activities undertaken.

Reporting and verification

Practices will need to complete the QI monitoring template in relation to this module and self-declare that they have completed the activity described in their QI plan. The contractor will also self-declare that they have attended a minimum of two peer review meetings. Evidence may be required by commissioners

We hope all of the suggestions are useful. Further, free support is available to suit your needs:

Dr Debbie Harvey, CRUK GP recommends the following top tips:

  1. Make sure you check what is taking place (or being planned) locally before you embark on your own planning and actions, so you don’t reinvent the wheel
  2. There may be specific cancer working groups which bring together relevant stakeholders that you could tap into
  3. Support will be available from a range of organisations including your local CCG, who can help co-ordinate activities, to avoid working in silos
  4. Make sure you link in with your local Cancer Alliance and public health teams who will likely have local plans and resources to support you.
  5. Your area may already have a CRUK Facilitator, CRUK GP, Macmillan GP or other cancer lead who will be aware of specific work around cancer which might support you and avoid unnecessary effort and duplication
  6. CRUK is well placed to help practices/PCNs, and it should be noted that CRUK is an integral part of the support system for GPs and PCNs