CS005 refers to the proportion of women eligible for screening aged 25-49 years at the end of period reported, whose notes record that an adequate cervical screening test has been performed in the previous three years and six months.

• QOF points: 7
• Lower threshold: 45%

CS006 refers to the proportion of women eligible for screening aged 50-64 years at the end of period reported, whose notes record that an adequate cervical screening test has been performed in the previous five years and six months.

• QOF points: 7
• Lower threshold: 45%

Commissioners may require that the contractor can provide a computer print-out showing the number of eligible women on the contractor list, the number with a personalised care adjustment, and the number who have had a cervical screening test performed at the appropriate time interval.

Women need to be sent a minimum of three invitations before the personalised care adjustment of not responding to invitations for care can be applied as described in Section 6 of the QOF guidance. Since 2019, there is a discrete SNOMED code (1109911000000100) to record that women have not responded to three invitations for cervical screening.

The requirement for women to be invited on three separate occasions will continue in line with national screening programme requirements. Therefore, in those areas where the first two invitations are sent via the central screening service, then contractors are responsible for offering the third invitation, or, where the central screening service sends out only one letter, the contractors are responsible for offering the second and third invitation. Where contractors have opted to run their own call/recall system, they are responsible for making all three invitations.

Women may choose to withdraw from the national screening programme. This should be undertaken with caution as women who withdraw from cervical screening call/recall will receive no further offers of screening from the central service. Where women actively decline cervical screening, this should be recorded as such. 

Further exclusions can include the following:

• intervention described in the indicator is clinically unsuitable
• the patient has chosen not to receive the intervention described in the indicator
• the patient has not responded to invitations for the intervention described in the indicator.

CAN001: The contractor establishes and maintains a register of all cancer patients defined as a register of patients with a diagnosis of cancer excluding non-melanotic skin cancers diagnosed on or after 1 April 2003.

• QOF points: 5
• Lower threshold: N/A

CAN004: The percentage of patients with cancer, diagnosed within the preceding 24 months, who have a patient cancer care review using a structured template recorded as occurring within 12 months of the date of diagnosis.

• QOF points: 6
• Lower threshold: 50%

CAN005: The percentage of patients with cancer, diagnosed within the preceding 12 months, who have had the opportunity for a discussion and are informed of the support available from primary care, within three months of diagnosis.

• QOF points: 2
• Lower threshold: 70%

A Cancer Care Review (CCR) is a discussion about a patient’s experience of cancer, delivered by a health or social care professional. The review can be carried out by primary care professionals with the right training (including GPs, nurses, or other allied health professionals). The achievement threshold set for this in QOF is 50-90%. 

The QOF includes the percentage of patients with cancer, diagnosed within the preceding 24 months, who have a patient Cancer Care Review using a structured template recorded as occurring within 12 months of the date of diagnosis. 

Tips and resources for Cancer Care Reviews 

The Macmillan Cancer Care Review guide is an extensive and recommended source of information. It includes, among other things:  

• Electronic Cancer Care Review templates (and instructions on how to access these templates on Ardens and EMIS) – EMIS diary can be used to set up a recall system 
• Guidance on how to prepare for a Cancer Care Review (including templates for sending an invitation by letter and sending a digital questionnaire) 
• 10 top tips for Cancer Care Reviews 

How to carry out a Cancer Care Review effectively  

• North Central London Cancer Alliance has produced this video to help GP practices carry out Cancer Care Reviews to a high standard.  

Patients should be given the opportunity for a discussion and informed of support available, within three months of diagnosis. Discussions should build on conversations patients may have had with secondary care, reinforcing information provided and taking a holistic view of support needs. 
Different approaches can be taken, with a focus on ensuring patients know how to access support from the practice. 
Discussions may or may not be clinician led or delivered through appointments, using the Macmillan template. Practices might feel that carrying this out through a different primary care team member or social prescribers is more appropriate.  
This work also forms part of the care standards which practices will evidence to the CQC, particularly in regard to supporting vulnerable patient groups. The achievement threshold set for this in QOF is 70-90%. 

We will be meeting with practices/PCNs to explain available data at place/borough level and discussing any local challenges, as well as where we can help or share available resources and education on carrying out this work to a high standard. 

Tips and resources for carrying out support discussions 

The discussion should also cover the following: 

• the patient’s diagnosis 
• the cancer treatment and its possible consequences 
• the patient’s prescription entitlements (and a medication review) 
• the patient’s and carers’ information needs 
• physical activity advice and signposting to local support services 
• signposting to Macmillan and other organisations. 

The Cancer Care Map can also help to signpost patients to relevant local services. 

Please note: The support discussion SNOMED code is Provision of information about cancer support services available in primary care (procedure) - SCTID: 1239881000000109