The ACE programme

ACE seeks to develop the knowledge base on early diagnosis in order to identify and evaluate good practice, which can reduce system delays and improve early diagnosis of cancer. ACE supports the NHS outcome 'preventing people from dying prematurely'.

The ACE programme: accelerates progress, coordinates implementation and consistently evaluates best practice and innovative approaches to early diagnosis of cancer.

Programme reports

The ACE programme pharmacy/primary care cluster is pleased to release two interim reports, the first on direct referral of suspected cancer patients by non GP primary care health professionals and the second on training of pharmacy staff for early diagnosis of cancer.

Variations in performance and practice

The lung cancer pathways interim report provides an opportunity to share some of the information gathered so far and to introduce the next phases of the process. There are six ACE projects within the Lung Pathway cluster, testing a range of different pathways and/or pathway elements as well as communication methods and motivation techniques. The majority of projects are trying to achieve better/faster access to CT.

The ACE Lung programme aims to help commissioners and providers to meet these standards by providing evidence of the impact of implementing particular changes, and by providing relevant information and tools that can be used to improve local services.

A more detailed analysis and evaluation of these six projects will be undertaken by the ACE programme in summer 2016.

Download the report

Lung cancer pathways: Interim report [PDF]

Setting up direct referral for early diagnosis of cancer

The first report presents two ACE direct referral projects, one involving community pharmacists and the other involving optometrists. The community pharmacy project is a direct referral to chest x-ray for people with suspected lung cancer being piloted by Doncaster CCG. The optometrist project is a direct referral to neuroscience for people with field vision defects being piloted by South Tees NHS Foundation Trust.

The aim of both projects is to identify and refer patients more quickly in order to improve early diagnosis of cancer and other conditions, and thus improve patient outcomes.

The report explains the rationale for the projects and how their direct referral pathways were developed and implemented. Key findings include the importance of effectively engaging all relevant local health economy partners and stakeholders and making sure that staff undertaking interventions have the right training.

Both projects are currently underway and a more detailed analysis of their impact will be undertaken by the ACE programme during 2016.

Download the report

Direct referral by non GP primary care health professionals [PDF]

Appropriate training helps pharmacies play a role in early diagnosis of cancer

Appropriate training of community pharmacy staff can enable them to play an important role in getting cancers diagnosed earlier, ACE recommends in its second interim report.

The report looks at how to best to organise pharmacy staff training for participating in early diagnosis related activities, including format and content and the costs involved. The report analyses five community pharmacy training programmes, including two ACE projects.

Key findings include that counselling skills training for pharmacy counter assistants are crucial and that pharmacists must be required to undergo specific training in order to undertake direct referral of patients to secondary care.

Download the full report

Pharmacy training for early diagnosis of cancer [PDF]


About ACE

The overall objective of ACE is to develop a body of evidence on different approaches to early diagnosis of cancer in order to inform future commissioning of cancer services. ACE has two key aims; first to help NHS organisations implement best practice including identifying and tackling system blocks, and second to test more innovative ideas such as streamlining current pathways and developing new pathways for vague but concerning symptoms.

ACE seeks to drive:

  • A shift from late to early diagnosis of cancer at stages I & II
  • A decrease in cancer diagnoses via emergency presentations
  • Improvements in overall patient experience

For an overview of the ACE programme please download this PDF.

ACE was established following an early diagnosis of cancer summit on 4 June 2014 convened by NHS England and held at the Royal College of General Practitioners in London. The summit was attended by a variety of stakeholders including leading clinicians, Public Health England, Clinical Commissioning Groups, Medical Royal Colleges, Macmillan and Cancer Research UK.

The ACE programme issued a call for projects in June 2014 with a deadline to respond of 31 July 2014. NHS England, Macmillan and Cancer Research UK all disseminated the call as widely as possible. The call asked for projects addressing the following areas:

  • Straight to test and one-stop clinics
  • Merging of referral routes – urgent and standard pathways
  • Multidisciplinary diagnostic centres (MDC or ‘Danish model’)
  • Self-referral for diagnostic tests
  • Pro-active approaches to high risk patients
  • Improving screening uptake generally and/or specifically in vulnerable adults
  • Use of IT in primary care to identify and/or flag high risk patients
  • Pathways for patients with vague symptoms
  • Lowering the thresholds for two week wait referrals
  • Greater role for pharmacists, opticians and other healthcare professionals in cancer referrals

Many NHS organisations across England submitted applications to have their projects included in the ACE programme. In total 89 expressions of interest (EOIs) were received and 60 projects were initially accepted into the ACE programme. The projects accepted into the ACE programme were grouped thematically into eight clusters as follows:

  • Lung cancer pathways
  • Proactive approach to patients at high risk of lung cancer
  • Colorectal pathways
  • Bowel screening uptake
  • Screening uptake for vulnerable groups
  • Vague symptoms pathways
  • Pharmacy/other primary care
  • IT tools


ACE structure and organisation

ACE programme structure

The Senior Responsible Officer (SRO) for the ACE programme is the NHS England National Clinical Director for Cancer. The programme is in the NHS England Early Diagnosis workstream which reports to the Cancer Transformation Board. Rosie Loftus, joint Chief Medical Officer represents Macmillan on Cancer Transformation Board.

Finance

The ACE programme receives funding from NHS England, Macmillan and Cancer Research UK. Up until March 2016, around £3 million will have been invested centrally. ACE provides only limited funding to projects, so most are funded locally, meaning overall investment in the ACE programme is much higher.

NHS England has provided funding for the Department of Health Policy Research Units (PRUs) to undertake the evaluation of the programme. Cancer Research UK is providing funding to cover the cost of programme team staff and for individual projects.

Macmillan is providing funding to cover the cost of one programme team member, Macmillan GP time spent providing primary care input to the ACE programme (where necessary), and for individual projects.

Projects accepted into the ACE programme can apply for funding to cover project management costs. In addition, ACE has funded modest one-off set-up costs for some projects.

ACE does not fund project running costs, so projects need to obtain such funding elsewhere. Project funding is provided via grant agreements with Macmillan or Cancer Research UK. Not all projects in the ACE programme have applied for ACE funding.


Why ACE?

England lags behind comparable European countries when it comes to cancer outcomes including one- and five-year survival rates, more details of which can be found in the international cancer benchmarking initiative.

One key factor for poorer cancer outcomes is late diagnosis, namely too many patients being diagnosed at later stages of cancer when treatment options can be limited, more onerous for the patient, and may no longer be curative. Improving early diagnosis therefore has the potential to drastically improve cancer outcomes.

Late stage diagnosis happens for a number of reasons including late presentation by patients and system delays including in referral to secondary care or for diagnostic tests. The ACE programme focuses on addressing system delays including the development and evaluation of new streamlined diagnostic pathways.

Other initiatives, such as 'Be Clear on Cancer', seek to raise public awareness and understanding of the signs and symptoms of cancer, to encourage people to present to their GP when they first notice symptoms that may be cancer.

ACE clusters

Bowel screening uptake

The projects in this cluster are exploring different ways to encourage people to undertake bowel cancer screening to increase screening uptake. A number of the projects include direct contact from GPs to individual patients.

It is hoped that the cluster can identify which methods of encouraging uptake work best, and how those methods can be implemented in a sustainable way.

A2 Wandsworth CCG

In order to achieve higher bowel screening rates towards the national standard for patients, practices are chasing non-responders of screening invitations by letter/phone. Each practice will do a search of annual non-responders followed by a monthly search to increase the earlier detection of colorectal cancer.

A17 Nottingham City CCG 

The project will raise awareness and improve the uptake of bowel cancer screening, working with local volunteers, targeting low uptake areas/practices linked to deprivation and BME groups.

A18 Luton CCG 

The project will raise awareness and improve the uptake of bowel cancer screening by working in collaboration with all GP practices, the local council, public health and cancer educators.

A20 Wessex Strategic Clinical Network

The project aims to reduce the inequality in uptake of bowel cancer screening, initially working with those areas and GP practices with below average uptake. Evidential learning from bowel cancer will be shared across other clinical areas as appropriate.

A29 Tower Hamlets CCG 

Through the improvement of systems, processes and IT solutions in primary care, the project aims to increase public awareness of cancer in high risk groups through community engagement, reduce delays in referral and diagnosis and increase uptake of bowel screening.

A30 Manchester Cancer

This is a pilot study exploring primary care involvement in re-engaging patients with the National Bowel Cancer Screening Programme who have previously tested positive on screening but failed to complete colonoscopy.

A34 North, Central & South Manchester CCGs

The project aims to use targeted support for GPs to code non-responders to the National Bowel Screening Programme, contacting patients to raise awareness and improve uptake. Non-clinical cancer champions will be the main point of contact for patients, following training and support.

A63 Merton CCG

Merton CCG is looking to develop a GP endorsement campaign for bowel cancer screening through pre-invitation and follow up for non-responders to improve uptake and raise awareness.

A50/A66 Cumbria Local Pharmaceutical Committee

The project aims to use healthy living pharmacies and cancer champions to raise awareness of lung and bowel cancer, including encouraging bowel screening uptake.

A86 Sunderland CCG

The project aims to increase the number of people taking part in the bowel screening programme through direct personalised communication from GP practices.

A89 Calderdale and Greater Huddersfield CCGs

Project members aim to improve the uptake of national bowel cancer screening programmes through personalised communication from GP practices direct to patients.

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Colorectal pathways

The projects in this cluster aim to streamline diagnostic pathways for colorectal cancer. Some projects do this via straight to test approaches such as GP direct access to endoscopy, others undertake triaged access to diagnostics.

It is hoped this cluster will identify the 'best first test' and 'best test mix' for diagnosing colorectal cancer as well as comparing straight to test and triaged approaches.

A6 East Midlands Strategic Clinical Network

The project will evaluate the impact of a number of interventions and pathway enhancements to improve the timely diagnosis and experience for urgently referred patients with oesophageal and gastric cancers.

A11 James Paget University Hospital

Project members will aim to reduce patient waiting time from referral to investigation and diagnosis of colorectal cancer by implementing STT flexi sig for appropriate 2WW referrals.

A22 UCL Partners, London Cancer

A quality improvement collaborative has been established to implement STT models of care across member organisations of London Cancer. These models will offer a faster pathway for patients, an effective diagnostic service for GPs and an efficient pathway for Trusts to increase earlier diagnosis of colorectal cancers.

A25 Wandsworth CCG

The project aims to provide GPs with a direct access diagnostic service for the referral of patients who have concerning lower GI symptoms, but who do not fit the 2WR criteria, primarily because of age.

A28 Wirral CCG and Wirral University Teaching Hospital NHS Foundation Trust

The project aims to develop an integrated model of care between primary and secondary care, avoiding duplication of clinical consultation, shorten time to diagnosis and MDT discussion, and reduce delays to treatment with no additional investment.

A59 Cambridge & Peterborough CCG

The project is evaluating the existing direct access diagnostic endoscopy service provided by In Health for patients that do not fulfil the 2WW criteria. The service will be evaluated against the service provided by Peterborough Hospital.

A61 Nottingham University Hospital Trust

The University Trust aims to reduce waiting time from 2WW urgent GP referral to investigation and diagnosis of patients referred with colorectal cancer symptoms.

A68 Wrightington, Wigan & Leigh NHS FT

The project will develop a STT service for 2WW suspected colorectal cancer referrals that will enable patients to be booked directly to endoscopy following triage for their diagnostic procedure, reducing waiting times to a maximum of 14 days.

A72 Croydon UHT

The project will provide a ‘one-stop, GP direct access service’ for the diagnosis of rectal bleeding and other high risk symptoms to promote the earlier detection of bowel cancer.

A74 South West Strategic Clinical Network

The project will evaluate the impact of STT approaches for patients with colorectal symptoms in order to develop a sustainable pathway. The project will also test the merging of referral routes to ensure both urgent and routine referrals are simultaneously fast tracked through the diagnostic process to timely treatment.

A79 South West Commissioning Support

In order to streamline the earlier diagnosis of colorectal cancers and ensure faster treatment, the project will pilot a STT electronic pathway that focuses on 2WW and routine referrals based on symptom criteria.

A80 University Hospital of Morecambe Bay

This project will implement a STT diagnostic colonoscopy service for patients referred via the 2WW pathway with colorectal cancer symptoms. The project will exclude patients under 40 and over 75 years of age – these patients would attend regular our patient clinics.

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IT tools

The projects in this cluster seek to embed use of the Macmillan electronic Cancer Decision Support (eCDS) tool in general practice to identify high risk patients and improve the appropriateness of cancer referrals.

It is hoped that this cluster will evaluate the impact of using the eCDS tool in general practice and identify how best to encourage and support GPs to incorporate the eCDS into their daily practice.

A45 London Transforming Services Cancer Team

Prospective audit of cancer diagnoses using the eCDS tool in a General Practice with 125 GPs.

A29 Tower Hamlets CCG

Development of template to record GP action following consultations using Macmillan eCDS tool to compare resulting cancer diagnoses with historic data/data from practices not using eCDS to ascertain impact on conversion rate of two week wait referrals and stage of diagnosis.

A48 Bridges Medical Practice, Gateshead

Testing the use of Macmillan eCDS tool risk stratification function to identify patients at high risk of cancer within a General Practice in Gateshead and then proactively inviting those patients to visit the GP where advice, referral or diagnostic tests may be offered as appropriate.

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Lung cancer pathways

The projects in this cluster are focused on streamlining lung cancer diagnostic pathways through the introduction of direct access to rapid diagnostics, with many projects seeking to implement 'straight to CT' pathways, i.e. diagnostic pathways which undertake a CT scan on a patient after a first unclear chest x-ray.

It is hoped that the cluster will identify the best way to integrate CT into the lung cancer diagnostic pathway and what is the best first test for lung cancer.

A14 Horsham and Mid-Sussex CCG

The project will develop a new pathway for cancer patients going to Brighton and Sussex University Teaching Hospitals (BSUH), which will involve going straight to CT following an abnormal chest x-ray.

A16 Nottingham City CCG

Through direct access to CT by GPs, when locally agreed criteria have been met, the project aims to improve 2WW pathway flow and appropriateness of straight to test and one-stop clinics referrals.

A26 King’s College London, Guy’s & St Thomas’ Hospitals NHS Foundation Trust, King’s Health Partners

Transforming Outcomes and Health Economics Through Imaging (TOHETI) project aims to facilitate direct access to imaging services from primary care, streamline diagnostic pathways and improve patient experience.

A60 Somerset CCG

The projects will complete an audit to review and establish key reasons for delay in presentation with lung cancer as well as develop and implement an integrated and streamlined lung pathway.

A65/21/76 (merged) Southend University Hospital, Basildon and Thurrock Hospital, and Mid Essex CCG

The above projects will work together to standardise and streamline their lung cancer pathway in the Essex region.

A71 Manchester Cancer and The Christie NHS Foundation Trust

The project will perform a data analysis to drive improvement of sectorised model of care, measurement and performance management and define quality standards of lung cancer pathways in Manchester.

A77 North Staffordshire University Hospital

To introduce a system by which an abnormal chest x-ray automatically triggers a CT scan request by radiologist, GP informed and eGFR requested – to reduce the anxiety of non-cancer patients and improve diagnostic investigation time for cancer patients.

A87 Crawley CCG

By developing a straight to CT following an abnormal chest x-ray pathway, the project has many aims including; promoting joined-up working between primary and secondary care and improving lung cancer survival rates through earlier detection.

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Pharmacy/other primary care

The projects in this cluster use non-GP primary healthcare professionals such as community pharmacists and optometrists to play a role in early diagnosis of cancer through awareness raising and direct referral to secondary care or diagnostics.

It is hoped that this cluster will identify how best non GP primary healthcare professionals can be utilised to contribute to early diagnosis of cancer including the effectiveness of direct referrals and patient engagement methods.

A1 Doncaster CCG

Cancer awareness raising activities through community pharmacies and community pharmacist direct referral to chest x-ray pilot.

A50/A66 Cumbria Local Pharmaceutical Committee

By using healthy living pharmacies and cancer champions, the project aims to raise awareness of lung and bowel cancer including encouraging bowel screening uptake.

A67 South Tees NHS Foundation Trust

South Tees Optometrist Referral Project (STORP) project aims to pilot direct referral to neuroscience from optometrists in Middlesbrough for people with field vision defects.

New reports

The first interim report of this cluster, which is on direct referral is now available: Direct referral of suspected cancer patients by non GP primary care health professionals [PDF].

The second interim report of this cluster, which looks at pharmacy training is now available: Pharmacy training for early diagnosis of cancer [PDF].

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Proactive approach to patients at high risk of lung cancer

The projects in this cluster are developing interventions to identify symptomatic patients who may be at high risk of lung cancer. One project includes a small pilot of patient self referral to chest x-ray.

It is hoped this cluster will identify the best ways to find people at high risk of lung cancer as well as assess the effectiveness of interventions offered to high risk people.

A33 Macmillan Manchester Cancer Improvement Partnership/Central, North and South Manchester CCGs, North West Lung Centre and University Hospital of South Manchester

The project aims to achieve a step change improvement in earlier diagnosis by utilising a risk-stratification process to identify people at highest risk of lung cancer; and then offering them a low dose CT scan as well as targeted smoking cessation advice and support.

A51 Liverpool CCG

The project will raise awareness of respiratory health and illness in communities with high incidence of lung disease and lung cancer. Members of the project will also work with GP practices to risk assess people, and offer low dose CT to those who meet agreed criteria.

A64 Mid Cheshire Hospitals NHS Foundation Trust

The project is focusing on health prevention and promotion of healthy lungs as well as the introduction of a self-request chest x-ray service targeted at populations where incidence and mortality is high.

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Screening uptake for vulnerable groups

The projects in this cluster seek to use opportunistic and community outreach approaches to encourage screening uptake in vulnerable groups such as people with learning disabilities and some ethnic minority groups. Projects use a mixture of GP outreach activity and community outreach in collaboration with voluntary sector organisations.

It is hoped that this cluster will identify best practice approaches to increasing screening uptake in vulnerable groups.

A27 Age Concern Central Lancashire and Galloway's Society for the Blind

The Voluntary, Community and Faith Sector will take a proactive, community based approach to improving diagnosis by engaging with vulnerable groups to raise awareness of screenings and achieve a more efficient pathway and timely diagnosis.

A46 Northumberland CCG

The project will look at whether personal contact from GP practices, to those patients who have failed to attend their third cervical smear invite, will improve uptake.

A47 North East and Cumbria Learning Disability Network in collaboration with the Northern England SCN (Cancer)

The key aim is to reduce inequality for people with a learning disability accessing the national cancer screening programmes. (Breast cancer screening, bowel cancer screening and cervical cancer screening.)

A49 Northern England Strategic Clinical Networks & Cumbria

The project seeks to improve participation in the NCSP across Cumbria, particularly in more vulnerable population groups, by increasing and adapting invitation and follow-up communications using text messaging.

A69 Durham, Darlington, and Tees Area Team & Tees Valley PH Shared Service

To raise awareness and improve the uptake of cervical screening in Middlesbrough, through direct personalised communication from GP practices.

A84 Blackburn with Darwen and East Lancashire CCGs

All practices will be required to plan and implement changes that have the potential of increasing uptake of all cancer screening in their patients with learning disabilities.

A85 North Kirklees CCG 

The project aims to improve cancer screening uptake in the South Asian community in North Kirklees. Project members plan to raise awareness with the local community groups, communicate findings to GPs and work with practices to improve myth busting with communities.

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Vague symptoms pathways

The projects in this cluster seek to implement diagnostic pathways for patients with vague but concerning symptoms, which may be indicative of cancer, but do not have an obvious possible tumour site. Projects include the establishment of Cancer of Unknown Primary/Malignancy of Unknown Origin pathways, acute oncology services and one project establishing a Multidisciplinary Diagnostic Centre (MDC).

It is hoped this cluster will identify the most efficient diagnostic pathways for patients with vague but concerning symptoms that may be cancer.

A4 Bury CCG 

The aim of this project is to develop a pathway for patients with vague symptoms within the named Strategic Clinical Networks (SCNs).

A7 Bristol, South Gloucestershire and Somerset CCGs and University Hospitals Bristol NHS Foundation Trust

This acute oncology project which sets out to 1) provide a more efficient pathway for urgent referrals where there is evidence of cancer but no signs/symptoms to suggest the location of the primary cancer (CUP) and 2) develop a service for dealing with patients with vague symptoms where cancer may be a diagnosis amongst other serious diseases.

A13 Chesterfield Royal Hospital

The project aims to establish a primary investigation clinic for those suspected (for any reason) of a diagnosis of a cancer where the primary tumour site is unknown.

A23 London Cancer

The project incorporates a Multidisciplinary Diagnostic Clinic (MDC) pilot aims to provide a timely diagnostic pathway for patients with abdominal pain, weight loss or painless jaundice, to improve patient flow and reduce unnecessary admissions for patients with these symptoms.

A32 University of Birmingham

ROCkeTS is a diagnostic test accuracy study that aims to identify, refine and validate tests and clinical risk scores (risk prediction models) that estimate the probability of having ovarian cancer in post and premenopausal women with symptoms.

A38 Airedale, Wharfedale and Craven CCG

The project aims to establish a new electronic referral system from GPs to radiology in order to get triage advice on the most suitable imaging for a patient with suspected cancer who presents with vague symptoms.

A52 Chelsea and Westminster NHS Foundation Trust

This Acute Diagnostic Oncology Clinic (ADOC), will set up and evaluate a five day direct access service for GPs to refer patients who 1) meet the criteria for a 2ww referral but are unable clinically to wait for the two week referral pathway, or 2) where the GP suspects the patient has cancer but does not know to which site specific team the patient should be referred.

A57 St Helens and Knowsley NHS Trust

The project includes a full CT for suspicious symptoms (CUP) to estimate incidence of suspected MUO cases that are not captured by existing 2WW, test use of CT CAP for this population.

A70 Manchester Cancer

The Manchester Cancer Jaundice Pathway project will provide earlier diagnosis and timely referral for patients with pancreatic cancer through same-day definitive radiological imaging and fast-track referral for early surgery.

A81 West Suffolk and Ipswich & East Suffolk CCGs and West Suffolk NHS Foundation Trust

East and West Suffolk CCGs and Hospital Trusts have put in place a simple pathway project to help manage patients with unexplained weight loss. 

A83 Slough 

Through retrospective study, the project aims to develop and evaluate a vague symptom referral/risk assessment criteria and a vague symptom diagnostic pathway.

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