Learning event analysis (LEA) toolkit for early diagnosis of cancer

The LEA toolkit supports primary care teams to conduct high-quality cancer LEAs, with the aim of improving individual patient and system outcomes in cancer.

What is Learning Event Analysis?

Learning Event Analysis is well established in Primary Care as a Quality Improvement Activity, which uses the review of specific cases in order to disseminate good practice and identify areas of concern for improvement that cancer cases can often represent.

The Cancer SEA template was initially designed because it was identified that cancer cases often lend themselves to the type of reflection that is fundamental to a good quality LEA, but that Health Care Professionals needed some guidance as to which issues to focus on to draw out the most impact from completing an LEA.

The development of Primary Care Networks and the associated requirements of the DES for Early Diagnosis with its focus on referral quality, consistent approaches to safety netting and unwanted variation mean that LEAs are encouraged as a key part of not only individual and practice level quality improvement but also wider learning across Networks and Clusters of Practices.

Although the original template is still an excellent tool to use, particularly for more complex cases, we have developed a simpler template that will hopefully still lead to detailed reflection of any case identified as ripe for learning but also, along with other elements of the new toolkit, to allow PCNs to capture key information from a number of practices to allow for a more analytical approach, thus supporting Community of Practice and Peer to Peer Learning at PCN Level.

Who is the toolkit for?

This Cancer LEA toolkit and its resources support members of Primary Care Teams in conducting high quality cancer LEAs with the aim of improving individual patient and system outcomes in cancer.

Download the Cancer SEA template

Encourage your practices to review your cancer diagnoses on a quarterly basis and bring them together to share any learning, specifically from any stage 3 or 4 cancer of patients diagnosed with lung or bowel cancer.

What is a Cancer LEA?

Whether clinical, administrative or organisational, carrying out an LEA on a cancer diagnosis encourages reflection of positive and negative actions and outcomes which can lead to quality improvements. Focus on the following should be considered:

  • What happened and why?
  • What was the impact on those involved (patient, carer, family, GP, practice)?
  • How could things have been different?
  • What can we learn from what happened?
  • What needs to change?
Any Cancer LEA should not allow patients to be identified but should comprise:
  • Title and date of the LEA discussion and subsequent events.
  • Date the event was discussed and the roles of those present.
  • A description of the event involving the GP(s) and other colleagues.
  • Reflections on the event in terms of knowledge, skills and performance.
  • Safety and quality.
  • Communication, partnership and teamwork.
  • Maintaining trust.
  • What areas of learning have been identified for individuals and the practice team as a whole.

A Cancer LEA is best done as a practice activity to be discussed and shared at a practice team or PCN meeting.

If a number of LEAs in the same area have been done, it is helpful to complete an LEA summary and then use this to draw together themes and trends. These can be analysed and highlight areas where change is required, which can then be shared with the team and assigned to the most appropriate person.

The Cancer LEA should document whether all relevant individuals attended and whether the conclusions should be discussed with any other staff inside or outside of the practice. An effective LEA not only identifies the learning points and actions to be taken, but also puts changes into effect and monitors their impact.

Specifying practice staff member or groups who will be responsible for the agreed action points and deciding how their impact will be monitored comprises a high quality Cancer LEA.

Case selection

Case selection is important – a case that encourages reflection and/or is likely to generate learning or change to practice is recommended.

The following are examples of cases that could make useful LEAs.

  • Emergency presentation of cancer.
  • Cancer diagnoses that may have involved a delay.
  • Cancers diagnosed at a late stage (Stage 3 or 4).

If doing as a practice or PCN-wide QIA, to maximise learning from LEAs it can be helpful to decide on a specific group or diagnosis to focus on. This is particularly helpful if there is evidence of inequalities, variation or issues pertaining to access to diagnostics for example, so that learning points and improvements can be drawn out and implemented.

Colorectal, lung, ovarian, pancreatic and neurological cancers (amongst others) are known to present at a late stage or as an emergency and therefore present opportunities for comparison and learning. However, deciding on the most appropriate group of cases to focus on for your own local area will lead to better learning and more likely impactful changes in practice or systems.

How to do a high-quality LEA

Both the Cancer SEA template and the new, shorter Cancer LEA template prompt clinicians to consider a number of factors, identification of which can encourage reflection and learning.

Capturing key demographic data such as this can add further depth to analysis, especially if the work is PCN-wide such as age range, smoking status, other comorbidities, cancer screening offer accepted/declined:

  • A description of the case – it may be helpful to include some of the following points where relevant:
  • Describe the route to diagnosis, including dates or timelines between consultations, referral and diagnosis and the clinicians involved in that process.
  • Consider the initial presentation and presenting symptoms (including where if outside primary care).
  • The consultation(s) at which the diagnosis was made.
  • Include any relevant consultations in the year prior to diagnosis and referral (such as how often the patient had been seen by the practice and the reasons for being seen).
  • The type of consultation held – virtual, face-to-face or home visit, and who consulted with the patient (GP1, GP2, Nurse 1).
  • Whether the patient had been seen by the Out of Hours service, at A&E, or in secondary care clinics.
  • If there appears to be a delay on the part of the patient in presenting with their symptoms, what may have contributed to this?

Reflecting on what went well and what to improve

You may want to consider:

  • Clinical, administrative and cross-team working issues – reflect on the process of diagnosis for the patient.
  • The stage of diagnosis – was the patient seen in the lead up to diagnosis? Was proactive or electronic safety-netting/follow-up used? Was there any possible delay in diagnosis and if so, what were the underlying factors that contributed to this?
  • What diagnostic services were used? Are there areas of education and training around cancer diagnosis and/or referral that could improve future outcomes? Has a recent change or development in a diagnostic pathway addressed some of these issues
  • Is there a need for protocols and/or specified procedures within the practice for cancer diagnosis and/or referral?
  • The robustness of follow-up systems within in the practice.
  • The importance and effectiveness of team working and communication (internally and with secondary care).
  • The role of NICE guidelines, NG12 suspected cancer: recognition and referral (2015) and their usefulness to primary care teams.

Analysing themes

If conducting a number of LEAs focusing on a specific area or topic, it might be helpful to consider some of the themes that often come up in Cancer SEAs. These include:

  • avoidable or unavoidable delays
  • vague clinical presentations
  • communication challenges
  • co-morbidities
  • complexity of the case
  • continuity of care
  • documentation quality
  • education and guidelines
  • in-practice systems
  • investigations and access to diagnostics, including impact of new pathways or potential guidelines, e.g. FIT
  • patient education and awareness, e.g. cancer in groups of patients you wouldn’t automatically expect, e.g. lower GI in patients under 50-years-old
  • practitioner issues
  • primary/secondary care interface
  • SNOMED coding
  • referrals management
  • routes to diagnosis
  • safety netting.

What changes are needed or have been implemented?

It is good practice to outline the action(s) agreed and/or implemented, including who has or will undertake them for the individual Practice. This can include:

  • Which staff members or groups will be/were responsible (GPs, Nurses, Receptionist) and how the related changes will be monitored.
  • If there are ‘actions’ that individuals or the practice as a whole will do differently, detail the level at which changes are being made and how are they being monitored.
  • What improvements will result from the changes? Will the improvements benefit diagnosis of a specific cancer group, or will their impact be broader?
  • Consider both clinical, administrative and cross-team working issues.

Making recommendations

Then consider and make recommendations based on your findings that may be of benefit to:

  • Other Practices in your area/PCN (improvements to practice systems, key education for Practice Staff).
  • Commissioners and Health Planners (e.g. Developments of new pathways/services or access to diagnostics).
  • Hospitals (Communication, positive/negative feedback on the current pathway).

Putting it all into practice

You can find an examples of good practice below. Cancer Research UK has also shared case studies where LEAs have been used.

Referrals audit – tackling variation of management of patients with unexplained weight loss*

  • Aim of initiative

    To decrease the interval between patient presentation with unexplained weight loss and 2WW referral across the PCN by 10%.

  • Background

    A practice conducted a review of two-week wait referrals in the last 6 months, and noticed patients presenting with significant unintentional weight loss were managed differently by different clinicians, with a wide range of the interval between the time patient presented with symptoms to the time the 2WW referral was made.

    The practice shared this at its monthly PCN meeting – the PCN had concerns of similar issues amongst other member practice referrals, and identified opportunity for a referrals audit as required in the PCN DES for 20/21.

  • Actions taken
    • The PCN suggested all its member practices carry out a similar audit and conduct a Learning Event Analysis for cases with the longest interval from symptom presentation to referral to reveal knowledge/skills/protocol or other issues which the practice might improve.
    • Encouraged by the PCN, each practice decided on an improvement plan that included measuring the impact of additional referral training on GP knowledge and confidence levels.
    • To support this the PCN produced a suggested list of education modules (e.g. Gateway C) for current NG12, investigations for weight loss and the relevant tumour groups.
    • A consultant from the local Rapid Diagnostic Clinic was also invited to one of the monthly PCN meetings to explain the service’s referral criteria for patients with vague symptoms, including weight loss, where cancer is a differential diagnosis.
  • Impact and evaluation

    Practices completed a second audit after 6 months and found interval lengths between presentation and referral had shortened by 12%.

    This information was used to support delivery of the QOF QI module.

    Referrals to the local Rapid Diagnostic Clinic increased, with some GPs making their first referral to the service.

*With thanks to Dr Winnie Kwan, Education Lead for South East London Cancer Alliance.

Referral audit – tackling late stage cancers in older people using a CDS tool

  • Aim of initiative

    To reduce the number of late stage cancers being diagnosed in older people across a PCN by undertaking a Learning Event Analysis (LEA) audit on all cancer diagnoses.

  • Background

    One practice within a PCN had participated in the National Cancer Diagnosis Audit, and audited 100 cases of patients diagnosed in 2018 while the 2 other practices had yet to decide how to approach the Early Diagnosis DES. The practice which had taken part in the NCDA shared its final report and reflected that the number of late stage cancer diagnoses was high.

    The practice cancer lead looked further at those cases by age group and found a number of late stage diagnoses were aged over 65 (compared with the national and CCG benchmark).

    Public Health England Fingertips data was shared, and the PCN reflected that they had an older population than the CCG benchmark – from this, the two practices who did not take part in the NCDA inferred that they may have a similar number of late stage cancer diagnoses over 65s (compared with the national and CCG benchmark), as the practice who completed the NCDA.

  • Actions taken
    • The two practices yet to complete the minimum 20 cases required for the Early Diagnosis QOF, decided to audit all cancers diagnosed in over 65s in 2018. Having completed their audit, the 2 practices found the majority of cases diagnosed in over 65s were also at an advanced stage.
    • The PCN organised a Community of Practice learning event with each practice submitting 3 Significant Event Analyses cases of late stage diagnosis in over 65s using the RCGP template. At the event, practices;
      • Discussed all 9 cases. In 2 cases the GPs reflected that while the patients were referred quickly by the GP, the patients did not request a GP appointment until their symptoms were advanced. In another 3 cases the symptoms were vague and so had been attributed to existing co-morbidities.
    • The PCN also arranged for the local branch of Age UK to attend one of its Community of Practice meetings to provide further insights into the challenges for older people in the area.
  • Impact and evaluation

    All 3 practices completed the audit again using the same template and noticed an improvement in the recognition of symptoms in older people and, in turn, more effective referral practices. They completed the same audit every 3 months for a year – this also supported the practices with their QOF QI module.

LEA templates

LEA Summary Template – use this to summarise and record the key themes from all LEAs undertaken to find common themes, or aid wider PCN level analysis and discussion: