Using practice data to engage GPs in early diagnosis

Cancer networks are reaching out to GPs in a year-long engagement programme, funded by the National Cancer Action Team (NCAT), aimed at facilitating the diagnosis of cancer.

Practice profiles have been produced by the National Cancer Intelligence Network (NCIN) for each practice, showing cancer incidence, type of referrals, screening rates and demographic and other data. NCAT funded GP leads in each network are encouraging practices to reflect on their profiles and identifying some practices for additional support. These practices will be funded to carry out an audit of recent cancer cases, to make any changes suggested by the findings and then to re-audit to examine the impact of the changes.

Within the aim of engaging GPs, the programme is flexible. Here some of the GP leads, and others, describe how they are adapting the work to suit local conditions.

Interpreting the data
Selecting the indicators to focus on
Two approaches to cold calling
From profiles to action plans

A training opportunity
Linking profiles to commissioning
Evaluation
Contacts

Lancashire and South Cumbria Cancer Network began work on the profiles by consulting widely and found a good opening in Blackpool. The medical director was about to visit all GP practices for their annual appraisals and agreed to take with her a pack with information about the profiles and the data consent form needed to release the profiles to practices.

Network information lead Neil Swindlehurst looked at the data for the town’s 23 practices and found four that were clearly out of step with the rest. Interestingly one of them was the medical director’s own practice.

The data presented a puzzle. ‘We found very good referral by two week wait. The practice was using the system well, and was pretty much in line with the PCT but still had high rates of emergency presentations.’ Neil believes the explanation is that the practice manages anyone who comes through the door well but a whole cohort never comes through the door, ‘a group for whom A&E is their surgery’, as he puts it. If the practice does the audit, it will be possible to confirm whether there is a group who bypass primary care altogether.

For Lancashire and South Cumbria, where the network has been charting two week wait and emergency admissions for several years and PCTs already support a high use of two week waits, ‘understanding such people is perhaps a bigger win, if we can learn how to target these people.’

As an information lead, Neil’s advice to others undertaking the profiles is to make sure they understand the data. ‘Make sure you judge everything within the context of the demographic population.’ But the main message is that ‘changing your practice locally can save lives’.

Professor Una Macleod of the University of Hull, who is leading for Humber and Yorkshire Coast Cancer Network, echoes Neil Swindlehurst’s warning about interpreting data. In singled handed GP practices, for instance, the numbers may be so small that it may be hard to draw any conclusions.

Even in bigger practices, interpreting the data can be a challenge. For instance when Una was in Scotland, she took part in an audit of urgent referrals that revealed higher rates of referrals for one training practice because the registrars were referring sooner than more experienced doctors. The valuable thing is the discussion this provokes. ‘If every practice looks at its referrals, it will have an impact on the quality of referrals.’

She is also looking forward to getting a closer look at the screening data for the network. She is aware from her own work of the effort that is required to reach people who don’t respond to invitations to screening and feels that performance measures don’t focus enough on reaching those who don’t respond.

The profiles show practice data compared to national and PCT figures for more than 20 indicators. Any that are significantly different from the average for the PCT are highlighted in orange. NCIN guidance suggests practices will definitely need attention if waiting time, presentation and diagnostic data are out of line with the PCT but demographic data are not. Practices may need attention where the demographic data are out of line, whether or not the practice indicators are also out of line.

The majority of networks are choosing to focus their attention primarily on practices’ record on two week waits and emergency presentations.

Kevan Ritchie who is the GP lead for the project for North Central London and West Essex Cancer Commissioning Network says interpreting the data is difficult because there is no right answer about what the figures should be.

In his PCT, Camden, practices are very engaged, there is a high use of two week waits and a low conversion rate of 7%. But is this good or bad? ‘Either they are not fully au fait with the guidelines or they are hyper-sensitive or two week wait is a short cut if there are delays in getting access to diagnostics.’

Even if the data can be interpreted with confidence, the message is still difficult as the risk of investigations and the anxiety they can cause, and pressure in the face of cuts to reduce referrals, have to be balanced against the chance of finding a cancer.

Once the practices that need attention have been identified, Kevan intends that the cancer leads in the PCTs will each have conversations with eight practices about their approach to cancer referrals and early diagnosis, reminding them about referral forms and where to get information. The leads will then pick two of the practices to do the audit.

Networks are taking different approaches to the question of how to deal with practices that don’t respond to the invitation to see their profile, but where the data suggest there may be a problem.

Mike Hotson, cancer commissioner for Leicestershire County and Rutland, is managing the project for East Midlands Cancer Network and working with the GP lead in his own patch. He is hoping to get network improvement facilitators to take a similar managing role in the other parts of the network.

‘We know there are interested GPs across the network and we hope that with a little arm-twisting we can persuade a number to become GP leads and work with their colleagues locally.’ Only GPs will approach practices. ‘When we wrote to GPs and said about the profiles being available, we were at pains to say this is not performance management.’

So far, across the network about 20% of GPs have requested to see their profiles and one in ten have already signed the data protection forms. Mike’s intention is that the practices that have been identified as needing attention will be contacted, even if they don’t ask for the data themselves. ‘The GP leads are likely to know the GPs so there won’t be much cold calling,’ he says. ‘There will be legitimate reasons why some practices are “outliers” in relation to some of the measures but the value for the practices will be in taking the time out to ask the questions of themselves with some peer support and come to an understanding as to the reasons for the observed variation.’

Mike is building on a solid foundation of GP engagement in his part of the network. About 60% of practices carried out the RCGP/NCAT national audit of cancer diagnosis in primary care in Leicestershire, Northamptonshire and Rutland during 2009/10.

In Pan-Birmingham Cancer Network a different approach is needed, as there was no primary care engagement before Jackie Dominey took on the job of GP lead for the practice profiles in November 2010. The network was not involved in the RCGP/NCAT national audit.

Jackie has had to start from the basics, getting up to date contact information for practice managers and sending out an invitation to sign up to see their profiles. She spoke to the local medical committees about the project and hopes to get some support from at least one of them.

Given the background, she feels it would be a waste of energy to carry on trying, if a practice consistently fails to respond. She would prefer to focus on working with some of the bigger practices, where changes will have the most impact.

She is optimistic about the reception the profiles will get. In talking to colleagues she works with in an after hours service, she has noticed that this group of relatively recently qualified GPs are keen to reflect and are used to doing audits. ‘I think it will be easier with the younger cohort than with GPs approaching retirement,’ she says.

Bruce Eden, GP adviser to the Greater Midlands Cancer Network, is building on his work with the RCGP/NCAT. The audit had a high take up in Greater Midlands and Bruce encouraged practices to draw up an action plan to implement any changes suggested by their audit. He is hoping to fund some of these practices to do just one follow up audit, to test the impact of their practice plan against the results of the original RCGP/NCAT audit. ‘Our previous report showed lots of system problems or doctor delays that could be put right. I hope that is what they will have put into the practice plans.’

He will also alert any practices where the data suggests there are issues they might want to reflect on and will invite them to contact him if they want to do a complete audit cycle. But like Jackie, he is doubtful whether a personal approach would be profitable in such practices, if he doesn’t already know any of the doctors.

Charles Buckley, primary care cancer lead for Gloucestershire and clinical lead for the project in 3 Counties Cancer Network, says a good proportion of Gloucestershire practices did the RCGP/NCAT audit and now he wants to take on Bruce Eden’s model of action plans. He would like to be able to fund some protected learning time for each practice so they can sit down and develop an individualised action plan using a ‘picking list’ of ideas. He is also intending to write to every practice which has orange dots for two week waits and emergency referrals and suggest they do a significant event audit (SEA) of their emergency admissions, believing this detailed reflective analysis will be more useful than repeating the audit.

‘Hopefully, if they do the SEAs systematically and analytically, they will build up a record of what has gone well and what not well, so they can do better in future.’ He is hoping to influence GP commissioning. Once the consortia have been agreed in the county, he intends to take the profiles and discuss what action needs to be done with local GP clusters and the evolving countywide consortium.

Pawan Randev is the primary care lead for North West London Cancer Network and will be acting as a mentor to the GP lead, Camilla Ducker, who will be leading the project. Pawan, who is a GP appraiser and trainer, intends to encourage practices to engage with the project as part of their professional training. Carrying out the audit will provide a block of evidence for revalidation that can be used by all the GPs in a practice. ‘I will email all practices with the offer of a supported audit and information about other activities to support revalidation.’

Pawan will offer online training in consultation techniques for cancer or suspected cancer, through a network-funded DVD developed for GP registrars, use of which would provide CME points. He has also written presentations for workshops that his GP leads will deliver to groups of GPs.

The email will go to all practices with the hope that they respond by asking to see their profile. Only those that have particular developmental needs, as evidenced by the orange dots in the profile, will be offered an audit but all will be able to take advantage of the on-line training and any workshops that are organised. Pawan will also be working closely with the GP trainer network to make the most of any opportunities to link the profiles to training.

Kent and Medway Cancer Network medical director for primary care Mike Parks is hoping to arrange educational meetings to talk about the process and the data to pass on learning points from the practices that have done the audits to those that haven’t, with a meeting in early spring in West Kent with the GP tutor. ‘It is another opportunity for primary care to focus on cancer.’

Mike believes that simply sharing the data will lead to a change in diagnosis. ‘Support for reflection in cancer data is worthwhile even if a practice already has a lot of interest in cancer.’

Anthony Gore, GP lead for practice profiles for North Trent Cancer Network, says this and other NCAT-funded projects have enabled GP leads in the PCTs to develop in ways that will be very helpful in the new world of GP commissioning.

As the GP cancer lead for Sheffield PCT, Gore had originally not had much contact with the network. Then through the network’s inequalities work in response to the Cancer Reform Strategy, and now through the practice profiles project, he has begun to operate at network level. GP cancer leads for the other PCTs have also taken on network responsibilities, such as pilot work on the new NCAT-funded risk assessment tool. ‘It has upskilled all of us,’ he says.

Having a group of GP leads with experience at both local and network level will be particularly useful as the new commissioning structures develop. ‘Probably people within the GP consortia have not thought about cancer yet, have not twigged how much of the general surgery budget is cancer treatment,’ he says. As a GP lead working at network level he can bring his own skills to help the consortia, and also can tap into the expertise of the cancer network, which includes people who are working at regional and national level. ‘I am useful because of the people I know,’ he says.

Philip Sawyer, primary care lead in Mount Vernon Cancer Network, believes the profiles will have more impact if they are linked to other initiatives around cancer and primary care. The network has relatively poor survival rates but a low incidence of cancer, which makes it harder to engage people in the cancer agenda.

The RCGP/NCAT audit has just been finished and results need to be fed back to GPs; work needs to be done with primary care to prepare for the regional pilot of the national bowel awareness raising project and a local lung awareness project; the network is piloting a new risk assessment tool; and new two week wait proformas need to be distributed.

‘We would like to have a communication highlighting all these issues in one hit. One of my concerns about practice profiles is that, if they are fairly average, they are quite difficult to get excited about. We want practices to see the bigger picture, how can they can help with this whole agenda.’ Each practice will be invited to nominate a GP to be the lead on cancer and to take the information to their practice for reflection.

Philip’s underlying aim is to get cancer onto the agenda of the new commissioning groups, in a similar way to North Trent. In addition to the NCAT funding for GP leadership, a new Macmillan project will pay for an extra one or two sessions a week for four GPs across the network. These GPs will discuss the profiles with practices in their localities and the wider agenda around cancer in primary care. ‘I want to get them up to speed so they will be able to support local practice based commissioning groups. Each GP lead will take one or two tumour site areas and work on some projects within that and on some network wide issues.’

Many of the networks are looking at ways that the profiles can help to support the shift to GP commissioning. Martin Huddart who is leading the project for North East London Cancer Network, says one of the keys to making GP commissioning work is having a machinery to understand the referral data. ‘An emergency admission with cancer costs three times as much as when the patient is referred on a two week wait. GPs will pick up on that.’

Practices could, for instance, train receptionists to release emergency appointments so that patients are seen that day rather than sent to A&E. Similarly the out of hours service could have a system of sending patients red flagged to the GP rather than A&E, if they have symptoms suggestive of cancer.

North of England Cancer Network director Roy McLachlan says the value of the project lies in broadening the range of people in primary care that the network is in touch with. ‘It almost doesn’t matter which practices you go to because somebody is having a dialogue about cancer and the practice is getting drawn into getting some support from the network and understanding how we can help. It is a really good way of opening doors, and very timely in terms of GP commissioning.’

Professor Greg Rubin of Durham University was part of the NCIN group that developed the project and is leading the evaluation of the practice profiles. Using a public health impact methodology known as Re-Aim, the research will interview participants in the project to chart what it set out to do and how well it has been done. Data will be gathered from practices that complete a full audit cycle to measure the impact of any changes that have resulted. GP leads will be sent a list of the information they need to record for the evaluation.

Greg’s researcher will not be collecting data on referral paths or changes in the practice profiles as this is held by the National Cancer Intelligence Network. However, the evaluation will have details of all the practices that have engaged in the project so the NCIN could analyse through future practice profiles change in this group compared to those that didn’t engage.