Working on the QOF Quality Improvement module on early cancer diagnosis

Icon for safety netting


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To account for the impact of the COVID-19 pandemic on care, the Supporting Early Cancer Diagnosis Quality Improvement modules is to be repeated in their intended [2020-21] format (prior to amendments for the refocusing of QOF in September 2020) with some slight modifications to account for the impact of the pandemic on care.

In addressing QIECD005 and QIECD006, practices are expected to undertake quality improvement activity in both screening and early diagnosis.

See the QOF guidance for 2021-22

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.

Get advice on how to meet contractual requirements in the QOF QI module on early diagnosis of cancer through this RCGP webinar, featuring CRUK’s Primary Care Advisor Dr Richard Roope, as well as GP experts Dr Amelia Randle and Dr Mike Jones

QOF QI requirements 2021-22

Identifying areas for improvement

Practices will need to:

  • Assess their practice screening programme uptake rates compared to local or national baselines. Practices should consider focusing on 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 (NCDA) or other retrospective audit of recent cancer diagnoses. Practices can use their existing 2019/20 NCDA audit report.
      • Practices may want to focus in more depth on cancers such as lung where there is often more unmet need and where, as a result of the pandemic, there has been a significant drop in the number of urgent cancer referrals and subsequent number of first treatments.
      • All tumour types have seen a drop in the number of first treatments; however, those where there has been the most significant decrease include the other most common cancers – breast, colorectal and prostate – as well as skin, bladder, head and neck, kidney and uterine.
    • 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:


Review the newly available PCN level reports for screening uptake on PHE Fingertips.  This will help you to benchmark your practices to understand any variation and to identify where improvements can be made for your PCN.

Public Health England have a dedicated section on their website about identifying and reducing inequalities in screening programmes. You can also watch the presentations on demand from the PHE Screening Inequalities Conference held in February 2021

  • 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.


  Download the CRUK useful tips for how, in your practice, you can support people to access cancer screening services during Covid recovery.

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

Public Health England 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


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.



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


Access the CRUK Covid Hub for health professionals to see the resources to support referrals during Covid recovery. Specifically:

  • Download the CRUK guide on recognition and referral of suspected lung cancer during the COVID-19 pandemic(link is external) 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.
  • Look at the short video on urgent referrals for suspected urological cancer - presented by Dr Joe Mays, CRUK GP
  • Access GatewayC’s resources on suspected cancer referrals during Covid. There is a useful range of free webinars, and short Covid-related updates

Access the CRUK Safety Netting hub which includes a Summary Table, Flowchart, Workbook and videos on how to use your clinical systems to embed safety netting. Look at your current safety netting processes and agree what best practice looks like and how you will collectively implement this, using the new Snomed codes for Safety Netting.


Ensure everyone in your practice is aware of and using the new SNOMED code for safety netting.



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 

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


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: