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The safety and governance aspects of cancer care in general practice – a managed clinical pathway
This paper is for education and debate
Cancer patients are in a vulnerable situation. They are treated with courses of medication and have
radiotherapy with known short and long term side effects. During the periods of their specialist care
they remain under the care of their primary care team. It is common for patients to present with
non- cancer related conditions to their primary care team. This team now consists of a larger
number of professionals, many working part time. Salaried GPs, Nurse practitioners, GP Registrars
and locum GPs form the workforce in addition to the traditional GP partner. The consultation length
is commonly 10 minutes so there is little time to take a history, examine appropriately and search
the medical record if more than one problem is presented or the patient is not known to the
professional. Thus a key element of patient safety is built into the continuity of medical record so
that all users of the record can be aware of the key issue that are relevant to that patient in a
highlighted, unambiguous way.
Organisational governance depends on the flow of accurate data and its review by clinicians, using
practice level audit data. Learning and changes made to pathways need to be shared within the
practice team and the larger organisation of the CCG.
1. Patients at increased risk of cancer should be identified by an appropriate alert system
during consultations and also identified by an audit process using the IT system. The CDS
pilot by Macmillan is an example.
2. Patients referred on a suspected cancer pathway (2 week wait) should be Read coded as
Fast Track Referral and a regular audit by administrative staff undertaken to ensure they
have been seen in secondary care.
3. Cancer patients should be coded from diagnosis using the standard QoF codes, as an active
problem, with date.
4. Patients on active chemotherapy should have this highlighted as a screen message, seen on
opening their record, with dates and type of chemotherapy. An example is long term
Herceptin which may be continued for years after diagnosis and so is relevant.
5. Known chemotherapy should be entered on the medication screen, with a clear message
that it is not to be dispensed in the community. This means that anyone prescribing is shown
all co-prescribed medication and has the safety of the interactions software built into all GP
systems. The treatment is placed into past drugs once the course is completed. The Clinical
Indication is added as free text and also the date for review/completion of treatment.
6. Treatment Summary letters from secondary/tertiary care are highlighted in the document
screen as being significant relevant documents. The problem header in the active problems
list highlights this as free text (in future a specific TRS Read code may be available).
7. The IT system features a metastatic cord compression risk alert – as developed for EMIS
Web (see appendix ). This needs to be developed for SytmOne and other recognised IT
8. Patient held records (PHR) of diagnosis/medication/treatment. The app is a
possible solution but our (Measham Medical Unit) experience of paper held records suggests
that this traditional approach is a cheap, reliable mode of sharing information with OOH
providers and others. It remains the preferred route for shared maternity records. The PHR
should contain a copy of the treatment record summary.
9. Regular annual audits of new cancer diagnoses are undertaken using the RCGP approved
10. Regular cancer specific Significant Event Analysis is undertaken within the whole practice,
using the RCGP approved template, with outcomes/learning being shared across the CCG.
Pawan Randev: GP Lead
Cancer Commissioning Team – North West and South
15 Marylebone Road
Tel: 0203 3504 534
Mob:07956 001887
Appendix 1
CDS tool screenshot
Appendix 2
Fast Track Referral codes
Appendix 3
Process and Screen shot of Chemotherapy screen message alert
Appendix 4
Screenshots/video of medication screen and alerts coming up
Appendix 5
Adding free text Clinical Indication and End date.
Appendix 6
TRS screen shot and highlighted in documents screen. TRS as active problem and free text to date in
documents system.
Appendix 7
Emis Web Cord Compression Protocol Alerts
Appendix 8 app
Appendix 9
RCGP audit tool
Appendix 10
Appendix 12
Chemotherapy App