QI Domain 2021/22: Early Diagnosis of Cancer QOF module

Breast screening

GP Dr Keith Hopcroft explains what the module involves, including the updated requirements for this year, and provides a suggested timeline to help your team complete the work efficiently.


The two QOF indicators in this module are:

QIECD005 – The contractor can demonstrate continuous quality improvement activity focused upon early cancer diagnosis as specified in the QOF guidance.

QIECD006 – The contractor has participated in network activity to regularly share and discuss learning from quality improvement activity focused on early cancer diagnosis as specified in the QOF guidance. This would usually include participating in a minimum of two peer review meetings.

The key elements are to review/improve:

  • Uptake of the practice population’s uptake of national breast, cervical and bowel cancer screening programmes.


  • Referral practices for patients suspected of having cancer.

It is worth noting here that, in light of the pandemic, NHS England emphasises two things:

  1. Urgent cancer referrals – both from GPs and screening programmes – fell significantly during the early phase of the pandemic, and although they recovered in late 2020 ‘it will be important to avoid a repeat of the steep fall in referrals we saw in April 2020’. Practices should ‘maintain an awareness of referral and testing pathways, including the impact of any pathway changes implemented as part of the pandemic response’.
  2. Referral rates were slower to recover on certain pathways, notably lung and urology, and the overall volume of people receiving first treatment for cancer in-year has dropped, so early identification of these cases will be especially important.

Detail and suggested timeline

1 Diagnostic phase (eg April -> July 2021)

The ‘diagnostic phase’ should a) evaluate the practice population’s uptake of screening programmes and b) assess how well the practice currently diagnoses cases of cancer at the earliest possible stage.

  1. Screening programme uptake: this should include an assessment of practice screening rates compared with local or national baselines. Various resources are listed for this in the guidance – most practices will find the Public Health England (PHE) fingertips tool for Cancer Services quickly provides all the information required. The guidance now also firmly advises practices to ‘consider how they can include a focus on inequalities in screening’ – useful background and suggestions on this are given on the Cancer Research UK website here.
  • Current referral practice: this could be achieved through
  • Participation in the National Cancer Diagnosis Audit. NHS England highlights that practices can use their existing 2019/20 NCDA audit report.
  • Other audits/reviews, eg, time from first presentation to referral; proportion of new cancer diagnoses referred using the two-week-wait referral route; proportion of new cancer patients diagnosed following an emergency presentation; proportion of new cancer patients diagnosed following a routine referral; safety netting of patients referred on the two-week pathway (eg, proportion of DNAs contacted by practice). The updated guidance also suggests practices look at ‘virtual versus face to face consultations’ as part of this.

Note: the guidance suggests:

  • Practices might want to make noteworthy cases significant event analyses.
  • Practices may want to focus in more depth on cancers where this often ‘more unmet need’ such as lung, but also where as a result of the pandemic urgent referrals and subsequent first treatments dropped – most significantly breast, colorectal, prostate, skin, bladder, head and neck, kidney and uterine.

Of note, last year’s version of the guidance previously suggested that audits should comprise at least 20 cases (no suggestion of adjustment according to list size).

2 First PCN QOF QI meeting (likely to be virtual) to create an improvement plan (eg, August 2021)

The precise plan will depend on the outcome of the diagnostic phase above, and could be agreed on a PCN-wide basis, or practice-by-practice. Possible ideas for quality improvements might include steps to:

  • Enhance overall screening rates for cervical, breast and bowel cancer (eg computer pop-up prompts for defaulters) especially for those programmes where there is poor uptake at Network level.
  • Reduce inequalities in the uptake of screening in certain population groups (eg provide a wider range of information formats)
  • Increase the proportion of cases in which cancer diagnoses are reviewed (eg a significant event analysis for every diagnosis made after acute admission)
  • A reduction in time from presentation to referral (eg a refresher on current NICE guidance for cancer referral)
  • An increase in the percentage of cancer referrals where safety netting is used (eg proactive contact of patients who do not attend two-week-wait appointments).

Note: set realistic and measurable targets for each aspect of the plan.

3 Implementing the plan (eg Sept -> December 2021)

  • Implement the plan agreed above and ideally involve patients (eg, patient participation group) in this and discuss how to sustain changes made.

4 Second PCN QOF QI meeting to discuss shared learning (eg Jan/Feb 2022)

  • Focus on shared learning from the QI activity and use this forum to discuss any system-wide issues identified in the process.

5 Completion of verification (March 2022)

  • Complete the QI monitoring template and enter relevant data onto CQRS.
  • Note that failure to achieve any targets set does not equate to a failure to achieve QOF points – these are awarded for participation, provided there is evidence of this.

Dr Keith Hopcroft is a practising GP in Essex

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