To fulfil the requirement to improve uptake in cervical and bowel NHS Cancer Screening Programmes, a primary care network (PCN) must:

• agree a series of actions, with agreed timescales, that will contribute to local efforts to improve uptake in cervical and bowel NHS Cancer Screening Programmes and review local data in the PCN cancer dashboard
• ensure that practices have set up tQuest and electronically request cervical screening tests in order for results to be fed back directly into the practice’s healthcare record system;  get in touch with the NCL Cancer Team for assistance in setting up tQuest
• follow-up on non-responders to invitations
• include at least one specific action to engage with a group with low participation locally; options include:
  • uploading the video on cervical screening for patients with learning difficulties to practice websites
  • performing a search for patients with HIV, as they should be on yearly recall
  • including cervical screening leaflets in different languages on practice websites or sending out relevant leaflets to non-responders
  • undertaking a training session with practice staff with the support of Jo’s Trust information
• increase contact for non-responders by a specific amount over a set period of time 
• use Screening Saves Lives promotional material for cervical screening 
• check that contact numbers of patients are correct.

Most practices will see patients with a new cancer diagnosis following assessment and management in a secondary or tertiary care setting. The CAN002 indicator aims to encourage GP practices to proactively provide patients with the opportunity for a discussion to make them aware of the support available from their GP and wider practice team. The intention is to facilitate early and supportive conversations, and to ensure that patients are aware of what help is available. 

The indicator supports recommendations 1.1.1, 1.3.4 and 1.3.5 from NICE guideline CG138 Patient experience in adult NHS services.

Please note: This indicator will only apply to patients who have received their diagnosis on or after 1 April 2021. For the purposes of this indicator, the 12 month timeframe starts from the date of diagnosis, irrespective of whether or not the diagnosis was made in primary care.

To fulfil this requirement, a PCN may wish to:

• send a letter to a newly diagnosed patient (a phone call, email or SMS is also acceptable); templates can be found on Accurx
• ensure consistent use of SNOMED codes.

A GP will have an average of eight or nine new cancer diagnoses per year, and will be looking after 20-30 patients with cancer. The increasing number of cancer survivors has led to an increase in the number of people requiring follow-up care, monitoring and management, and therefore primary care has an important role in supporting people to live well with and beyond cancer.

The Cancer Care Review (CCR) represents an opportunity to address patients’ needs for individual assessment, care planning and on-going support, and information requirements.

The Macmillan CCR page can be used as an aide memoire when carrying out a CCR. It also includes supporting information which can be shared with the patient, in addition to providing a helpful coded record of topics discussed and guidance for the various templates used (see slide 26 for downloadable templates).

Macmillan also provides top tips on completing effective CCRs, which encourage a fuller discussion of the diagnosis and recording of cancer therapy, an offer of relevant information, a medication review, benefits counselling and recording of a carer’s details. Top tips on late effects, fatigue, anxiety, nutrition and other common problems are also available via the NCL Cancer Alliance YouTube channel. 

Further information on care following a cancer diagnosis and the potential role for primary care can be found on the Macmillan website.

For the purposes of this indicator, the 12 month timeframe starts from the date of diagnosis, irrespective of whether or not the diagnosis was made in primary care. This indicator will not include patients whose latest unresolved cancer diagnosis was earlier than 1 January 2021, as these patients should have already been reviewed. 

To fulfil this requirement, a PCN should use Macmillan’s national, integrated electronic CCR template within primary care IT systems to support well-structured reviews.

An Accurx Florey called Cancer Care Review Questionnaire has also been recently developed, which can be sent out pre-CCR to allow the patient to think about issues and reply with what they want to focus on. The Florey pre-CCR should be sent out prior to the CCR and is not sufficient on its own. Information on the Florey and how to access it can be found on the Accurx website.

A Time of Diagnosis letter template is also available. This can be sent to patients via post, email, text, or it can be discussed with the patient verbally. At the time of providing the information to patients, it needs to be coded in the system as a Provision of Information about Cancer Support Services in Primary Care.

Please note: The CCR SNOMED code is 720006006.