Practical Implementation Guide for Cancer Care Reviews

What is Cancer Care Review?

A Cancer Care Review (CCR) is a conversation between a person living with cancer and their GP Practice about their cancer journey. The patient can invite a carer, family member or friend to be part of that conversation. The conversation could be by telephone, video, or face-to-face.

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.

Personalised care means people have choice and control over the way their care is planned and delivered. It is based on what matters to them and their individual strengths and needs.

Critically, personalised care takes a whole-system approach, integrating services for the person, including health, social care, public health and wider services. Those who perform CCRs are essential in supporting personalised care.

Frequently Asked Questions (FAQs)

  • What are the drivers for the role of Primary Care in supporting people after a cancer diagnosis?
    • Increased incidence and survival of cancer
    • People living with cancer should be supported like other long-term conditions, which are already well managed by Primary Care
    • National Cancer Patient Experience Survey results consistently demonstrate poor care ‘out of hospital’
    • NHS Long Term Plan promotes interventions that support personalised care
    • Quality Outcomes Framework (QOF) included cancer indicators from April 2021 and remunerates general practices for providing good quality care.
  • What are the benefits of completing CCRs?
    • Delivery of personalised cancer care and support
    • Improves communication between primary and secondary care
    • Enables secondary care to refer issues that need community support/social prescribing
    • Reduces GP workload
    • Adds value to practice services
    • Improves experience of people living with cancer
    • Meets Quality Outcomes Framework (QOF) standards
    • Maximises income from QOF to invest in other services
    • It allows for healthcare professionals undertaking the CCRs to develop professionally and access learning opportunities, which can be applied to other long term conditions.
  • What are the Quality Outcomes Framework (QOF) requirements for 2023/24?
    • CAN001: Practice establishes and maintains a register of people diagnosed with cancer (5 points)
    • CAN005: 70-90% of people with cancer will be offered an opportunity to discuss and be informed of the support available within 3 months of diagnosis (2 points)
    • CAN004: 50-90% of people with cancer will have a structured Cancer Care Review (CCR) recorded within 12 months of diagnosis (6 points)

How to prepare for Cancer Care Reviews

Before you start completing CCRs, you might want to consider the following.

    • Your local Macmillan Partnership Team can support you and help make introductions
    • Find out who is the Lead Cancer Nurse and make contact to introduce yourself and explain your role
    • Identify all the multidisciplinary oncology teams (MDT) that work in the centre or unit
    • Create a Directory of Contacts from the centre or unit – names may change but contact details rarely do. The Lead Cancer Nurse may be able to provide contact details for you
    • Find out how best to communicate with them. You may want to know do they have a dedicated phone number or email address? Is there a generic tumour site team email?
    • Find out whether they complete Treatment Summaries and/or Holistic Needs Assessments as part of the treatment pathway and how they will share them with you
    • Suggest that the MDT inform patients that they will receive an invite for a CCR from their GP Surgery. Download our postcard that could be given out at time of discharge from secondary care.

Which CCR template is compatible with your IT system?

Macmillan have created CCR templates for most Primary Care Operating Systems.

  • 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'.

Setting up QOF Indicator CAN005

The QOF Indicator CAN005 encourages GP practices to proactively provide patients with the opportunity for a discussion within 3 months of diagnosis. The discussion should make the patient aware of the support available to them at the practice and locally within the wider community.

Before contacting patients make sure to check:

  • that a new cancer diagnosis code has been added as a problem by the GP, to ensure that they are added to the Cancer Register (CAN001), and they have definitely been diagnosed with cancer
  • which communication methods are preferred by the patient
  • the diagnosis, location of cancer and staging of the patient's cancer.

Download our example invitation letter that can be sent to patients.

Once discussion opportunity has been offered, move the patient over to the 12 month spreadsheet.

Setting up QOF Indicator CAN004

  • Either use Macmillan Template on your system or manually code using the following SNOMED Codes:

    • SNOMED Code 1239881000000109 - Provision of information about cancer support services available in primary care
    • SNOMED Code 1187911000000105 - Personalised care and support plan agreed.

Top Tips for meaningful Cancer Care Reviews

  • Often CCRs can be emotionally draining, run over the 30 minutes appointment time and there may be actions that you need to follow up on. So try to manage the number you complete in one day.

    You can acess a range of online courses to help you look after your mental health and wellbeing on Macmillan's Learning Hub.

Using the Macmillan e-HNA Platform

Our guide to using eHNA via covers how to get started and gives step-by-step guidance to using the Macmillan eHNA and the Care & Support planning tools.

eHNA and User Guide [PDF]

You can also see what the assessment tab would look like for a real service user who has completed the assessment here.

View an example of a completed My Care Plan from the e-HNA Assessment [PDF].

Evaluation of Cancer Care Reviews

Before starting CCRs, you may want to consider how you will demonstrate that the needs of people living with cancer have been met and how you will capture their experience of care.

The evaluation of CCRs is important because it allows you to:

  • assess the effectiveness and quality of reviews
  • focus on the outcomes and impact of reviews
  • determine what works well and what could be improved.

Below are resources and examples that have been used to evaluate the effectiveness of and the experience of CCRs:

We also have an example of a questionnaire to evaluate your CCRs.

You can also find the audit results of the above questionnaire used for one Practice here.

Further information and resources

Find a list of further recommended reading and training courses below.

About our information

Last updated: December 2023

  • Jacqui Graves – Macmillan Clinical Nursing Advisor for Primary Care and Cancer Care Nurse in Primary Care

    Han Wang – Clinical Engagement Officer, Macmillan Centre of Clinical Expertise

    Sian Lambert - Cancer Care Coordinator Project Manager, Kent and Medway Cancer Alliance, NHS Kent and Medway Integrated Care Board (ICB)

    Sandra Dyer – Primary Care Lead Nurse, Transforming Cancer Services Team for London, Healthy London Partnership and Advanced Nurse Practitioner in Primary Care

    Anthony Cunliffe – Lead Medical Advisor, Macmillan Centre of Clinical Expertise

    Nicola Macfarlane – Primary Care Cancer Facilitator Southwark, South East London Integrated Care Board

    Pam Kay – Primary Care Facilitator for Right By You Project/Cancer Care Nurse in Primary Care

    Andrew Brittle – eHNA Digital Product Owner, Macmillan Cancer Support

    Emma Brooks – Professional Development and Knowledge Lead, Macmillan Cancer Support

    Julie Cracknell – Macmillan Personalised Care, Cancer Nurse Facilitator (Swindon Primary Care).