Cancer Care Review
On this page
What is a Cancer Care Review?
What are the QOF requirements?
Supporting patients after a cancer diagnosis
How to prepare for a Cancer Care Review
What should a Cancer Care Review include?
Electronic Cancer Care Review templates
Sharing a personalised care and support plan
Training courses for Primary Care
Involving social prescribers and cancer care coordinators
For your patients
A Cancer Care Review (CCR) is a conversation between a patient and a Health or Social Care professional about their experience with cancer. It is essential to personalised care and helps patients to:
- talk about their cancer experience and concerns
- understand what support is available in their community
- receive the information they need to begin supported self-management.
In the video below patients share their experiences about cancer care reviews.
Changes to the QOF requirements 2023/24
In recognising the important role that primary care plays to support people after a cancer diagnosis, changes have been made to 2023/24 Quality and Outcomes Framework (QOF) cancer requirements.
The changes focus on key times of need, when patients may feel vulnerable. These include:
- at the time of a patient's diagnosis (within 3 months)
- after a patient has received acute treatment (within 12 months).
The QOF also specifies that practices should use Macmillan’s national, integrated electronic CCR template to support a well-structured review. Find out how to access the CCR templates in your primary care IT system.
2023/24 QOF indicators
We have included the QOF indicators related to CCRs below.
|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 (NICE 2020 menu ID: NM205)||6||50-90%|
|CAN005. The percentage of patients with cancer, diagnosed within the preceding 12 months, who have had the opportunity for a discussion and been informed of the support available from primary care, within 3 months of diagnosis (based on NM204)||2||70-90%|
A cancer diagnosis can be a difficult time for patients. As recognised with the introduction of the CAN005 indicator, primary care professionals are now required to reach out to patients who have received a diagnosis.
We recommend getting in touch with your patients in the following ways:
A telephone call or virtual consultation
Primary care teams may choose to reach out with a telephone call or virtual consultation after they learn of a patient’s diagnosis. This gives the patient an opportunity to discuss their concerns and express what support they may need. You can also use this time to signpost patients to local support or let them know all the ways we can support them.
Sending a letter
Your practice may already have a robust process for contacting patients after a new cancer diagnosis. This is a helpful way to let patients know you are there for them. You may also choose to send a letter to advise patients about the help that is available. We have created a sample letter which can be personalised to include links to support from Macmillan and the option to include local services.
Sending a text message
We worked with accuRx to create an SMS text message template you can send to patients. The SMS signposts patients to trusted information and support after a cancer diagnosis. To use the SMS template, search for the template title ‘Macmillan Support Services’ or find it via this pathway in your accuRx system: Clinical > Useful services.
Supporting patients after a cancer diagnosis is the first QOF requirement for primary care professionals. We have more information about supporting patients from diagnosis.
After you have reached out to your patient following a diagnosis, it can be helpful to give them time to prepare for a CCR conversation. Primary Care teams now need to offer a patient the CCR within 12 months so it can coincide with the end of their cancer treatment. We recommend getting in touch with patients by:
Sending an invitation by letter
You may decide to invite the patient for a CCR by sending a letter in the post. This helps patients to understand the purpose of the review and consider any issues they would like to discuss. A copy of a Concerns checklist can be sent with the letter to help them prepare. Download the CCR invitation sample letter.
Sending a digital questionnaire
We have developed a Cancer Care Review Patient Questionnaire as a Florey Survey in accuRx, which can be sent to patients by SMS text message before their CCR.
The questionnaire is quick and easy to complete on a smartphone and helps the patient and physician prepare for the CCR conversation by highlighting their most important concerns.
The Macmillan Cancer Care Review Questionnaire Florey can be found under the ‘Partnered’ list when selecting a Florey template.
AccuRx has created a step by step guide on using Florey Surveys.
In the video below healthcare professionals share their experiences of using cancer care reviews and how they can help personalise care for patients.
An effective CCR conversation should aim to discuss:
- the patient’s diagnosis
- the cancer treatment and its possible consequences
- the patient’s prescription entitlements (and a Medication Review)
- the patient and carers’ information needs
- physical activity advice and signposting to local support services
- signposting to Macmillan and other organisations.
Evidence found that use of a structured template alongside quality improvement activities for holistic cancer care reviews enabled higher quality personalised care conversations to happen.
We have more information about our electronic CCR templates and how to share a record with patients below.
We have also listed our 10 top tips for effective Cancer Care Reviews.
The Quality Outcomes Framework (QOF) specifies the use of Macmillan’s electronic template to guide the CCR conversation. This helps to ensure the patient’s holistic needs are identified and considered.
CCR template update (3 month review)
Following the 2023/24 QOF changes, we have updated the Macmillan CCR template on all major IT systems. The update introduces a new ‘Initial 3-month review’ tab that supports the CAN005 indicator and allows professionals to meet the requirements of the initial review, before the full review within 12 months.
How to access the templates
You can access the templates on the following GP IT systems:
Macmillan has worked with Ardens to align their CCR template with our national standardised template.
If your practice is on Resource Publisher, the Ardens CCR template titled 'Cancer (v15.1)', is located in: Shared folders/Ardens Main/Ardens LIVE Toolset/Chronic Disease Templates.
If your practice is on Template Manager, it is located in: Ardens (vX.X)/Chronic disease templates. This template can be accessed from the template picker by searching.
The EMIS template is located in: EMIS Library > EMIS Protocols > Third Sector Partnerships > Macmillan/Cancer Support > Macmillan Cancer templates.
This template can be accessed from the template picker by searching.
To access the CCR template in INPS Vision: In the Vision+ Consultation Manager, select the arrow on the right-hand side of the + icon and select ‘clinical templates’.
To access the CCR template in the TPP SystmOne: System > Resource Library > type 'macmillan' as the key search term and look for 'Macmillan Cancer Care Review Template 2021'.
We have also produced an Personalised Care Quality Improvement toolkit to support the template. It contains searches to help practices demonstrate and monitor quality improvements to CCRs.
Want help to access the template or searches on your system? Please email email@example.com.
The Cancer Care Review in Primary Care is an essential intervention in delivering Personalised Care to People Living with Cancer. To support healthcare professionals to facilitate these conversations and ensure the patient has a record of what was discussed, including any advice and information given, we have created a Personalised Care and Support Plan template.
This template will allow the patient’s agreed priorities, concerns and next steps to be documented and shared with them, to provide effective continuity of care that is personalised to them.
We offer training courses to support healthcare professionals with CCRs.
- Practice nurse course
If you are interested to find out about our practice nurse course, please email our Professional Development and Knowledge team for information on upcoming places.
Find out more about learning and development courses for healthcare professionals.
Social prescribers, cancer care coordinators and link workers are well placed to work alongside primary care professionals, where they can identify and signpost patients to information and local support services.
For more information on the role that social prescribers and cancer care coordinators can play in supporting people living with cancer and how Primary Care Networks can get the best out of these roles, download the following PDFs:
Macmillan Cancer Support
- 10 top tips for social prescribing in primary care
- 10 top tips for virtual consultations in primary care
- Supporting early diagnosis: A quality improvement toolkit for primary care
- Social prescribing for cancer patients: A guide for primary care networks
- Evaluating the effectiveness of a CCR template in primary care.
For your patients
Our specialist advisers can give advice and support to your patients. Encourage them to call us on 0808 808 00 00 (7 days a week, 8am-8pm).
It’s quick and easy to order free booklets to give to your patients, their families and carers. Topics include cancer types, treatment, and emotional support.