This toolkit aims to support GPs, practice staff and commissioners in conducting high quality cancer Significant Event Analysis (SEA) with the aim of improving patient outcomes in the early diagnosis of cancer.
Cancer SEAs prompt a GP to reflect on their diagnosis, and identify any potential improvements in practice systems using documentation or proactive safety netting.
At CCG level, a cancer or quality improvement lead may find emerging themes and use local intelligence to address and manage issues. Cancer SEA can support dialogue between the primary and secondary care interface and have benefits for clinicians, practices and patients.
This toolkit may be used by CCG or cancer leads, practice GP leads or any GP in a practice delivering training to inspire and engage GPs by demonstrating the worth of a quality cancer SEA.
The toolkit includes guidance for leads to extract themes from SEAs in order to make recommendations for quality improvement in general practice and across the primary-secondary care interface.
The following resources have been developed with a ‘train the trainer’ approach as a guide to the process involved in completing an effective SEA.
What is a cancer SEA? This infosheet looks at the cancer SEA process, the questions it should answer, its components, and implementation in a practice setting.
Process flowchart This flow chart shows a continuous cancer SEA Quality Improvement process that may be implemented in your CCG.
Case selection Infosheet on the importance of case selection for a cancer SEA and tracking a practice’s cancer activity.
How to undertake a high quality SEA
These resources and tools can aid in the undertaking of a high quality Cancer SEA. They include cancer SEA template, instructional video and infosheet on using the template.
The feedback instrument tool
A feedback instrument tool (2015) was developed by Macmillan and RCGP. This tool can be used by individual GPs or practice teams to self-appraise their cancer SEAs. Guidance for peer-reviewers is included.
This ‘Analyse Themes‘ infosheet helps explore whether reflection has been extensive and identifies themes that could have been discussed or actioned more effectively.
Actions and impact
This ‘Actions and Impact‘ infosheet looks at how employing effective team meetings, agreeing actions, and measuring impact are a crucial part of the cancer SEA.
The following fictional example cancer SEAs demonstrate a varying range of quality. Each contains detailed notes showing both positive and negative examples of reflection, subsequent actions, and impacts following a cancer diagnosis.
The three examples are centred around colorectal and ovarian carcinoma, two cancers known to present as an emergency.
SEA Patient A An example where reflection could have been deeper.
SEA Patient B An example describing a clear timeline of events, however it could demonstrate deeper reflection, more specific learning action points, and the impact on practice.
SEA Patient C An example which is thorough in its discussions and demonstrates insightful reflections, specific learning and action points.
These fictional examples can be used to demonstrate best practice in cancer SEAs, and where improvements can be advised to GPs.
The Cancer SEA GP guide can be used by any GP wishing to undertake a Cancer SEA. The guide can also be issued as a ‘hand-out’ for GPs in your training events.
‘Early Diagnosis of Cancer – Quality Improvement Using Cancer Significant Event Analysis’ training session resources
The following resources consist of a presentation that can be adapted for your training events, and resources to support this:
Resources for training sessions:
• Cancer SEA Template (2016)
• Instrument feedback tool
• Workshop brief
• Example SEA – Patient A handout
• Example SEA – Patient B handout
• Example SEA – Patient C handout
• Example evaluation form
Safety Netting may support healthcare professionals to detect cancers earlier and minimise delayed diagnoses. It is a technique which can be used to ensure the timely re-appraisal of a patient’s condition. This is important for conditions such as a suspected cancer where patients present infrequently with common and often non-specific conditions.
Safety netting resources
The following presentations were developed for this toolkit but can be adapted and used as needed. They contain detailed information, background and tips on safety netting, why and how to use it, and information on coding. These may also be used or adapted in a training context.
Safety netting background information
Safety netting guide Includes a summary of Oxford University research on safety netting and introduction.
London Cancer & Macmillan Safety Netting Guide A guide to safety netting from London Cancer and Macmillan Cancer Support.
- Cancer Decision Support (CDS) tool
The CDS tools are designed to support GPs in their clinical decision making and encourage them to think cancer by displaying the risk of a patient having an as yet undiagnosed site-specific cancer. This risk is based on read coded information from their patient record including symptoms, medical history and demographic data and uses either QCancer or RAT to calculate the score.
To find out more, including whether the CDS tool has been integrated in to your IT system, please visit the CDS Promotion Pack
- QCancer calculates the risk of a patient having a current but as yet undiagnosed cancer, taking account of their risk factors and current symptoms. This tool is designed to support clinical decision making and does not replace clinical judgement.
- Cancer Risk Assessment tool (RAT) is an algorithm that can be used to calculate the absolute risk that a patient has an undiagnosed cancer based on certain risk factors and their current symptoms. The RAT is designed to support clinical decision making and does not replace clinical judgement.
For more information on prevention, screening and treatment of cancer in primary care, please visit the Primary Care Cancer toolkit. For further information on identifying and managing the consequences of cancer treatment, and supporting patients to live well after a diagnosis, please visit the Consequences of Cancer toolkit. For specific referral guidance, please visit the Brain Tumours in Children toolkit.
With funding from NHS England and Macmillan Cancer Support, and developed in partnership with the Clinical Innovation and Research Centre (CIRC), this toolkit combines a body of work to assist general practices. The toolkit aims to help the College work toward the pledges made in the RCGP Position Statement on cancer in primary care.
• Steering committee members
• London Cancer
• Transforming cancer Services Team Healthy London Partnership
• NHS Gloucestershire CCG
• NHS Birmingham Cross City CCG
• NHS Education Scotland
• University of Leeds
• The Hull York Medical School
Information for Commissioners
The Cancer Task Force published Achieving World-Class Cancer Outcomes – A Strategy for England 2015-2020. It contained 96 recommendations across primary, secondary and public sectors. Recommendation 25 stated GPs should be required to undertake a Significant Event Analysis for any patient diagnosed with cancer as a result of an emergency presentation. The SEA template used for this project is the ideal quality improvement tool to implement this recommendation.
A key part of the strategy includes reducing emergency presentations of a new diagnosis and deciphering whether there are specific avoidable contributors; currently just over 20 per cent of all cancers in England present via this route. This Cancer SEA Quality Improvement toolkit for the Early Diagnosis of Cancer can be used to support CCG cancer leads and Macmillan GPs to deliver localised schemes aligned with the cancer strategy and embed their use alongside safety netting and risk assessment tools to improve early diagnosis.
Background on Cancer SEAs
Significant Event Analysis (SEA) is an approach to quality improvement now well-established in general practice. It involves a structured review of all that happened in relation to the event of interest, which may be adverse, exemplary or simply important. The requirements of the Care Quality Commission, annual appraisal and revalidation are increasing emphasis on the quality of continuing professional development and reflective practice.
Between 2009 and 2012, the RCGP in collaboration with NCAT and the Department of Health developed a cancer-specific SEA template as a quality improvement tool with accompanying advice on its use. This proved popular with practices and cancer networks. The template was designed to support GPs to not only complete a quality cancer SEA to a high standard but also as a real vehicle for change with an emphasis on reflection with a non-judgmental approach.
The RCGP has produced a Quality Improvement guide for General Practice to support the whole primary care team on their quality improvement journey.
The RCGP and Macmillan Cancer Support have continued to champion the use of cancer-specific Significant Event Audits with respect to early diagnosis. In 2014 the RCGP partnered with Macmillan Cancer Support to train appraisers to effectively appraise Cancer Significant Event Audits in a way that supports quality improvement in patient care. In this initiative, systematic peer review was incorporated under the imprimatur of the RCGP, in a pilot that was promoted through cancer networks.