Evaluation of the Research UK Primary Care Facilitator ... · Evaluation, Research and Development...

School of Medicine and Health Wolfson Institute for Health and Wellbeing Queen’s Campus

University Boulevard Stockton on Tees TS17 6BH UK

Telephone +44 (0) 191 334 0518 Fax +44 (0) 191 334 0361

E-mail [email protected] www.durham.ac.uk/school.health July 2014

Evaluation, Research and Development Unit

Evaluation of the Cancer Research UK Primary Care Facilitator initiative 2013/14 Dr Ingrid Ablett-Spence Ms Carolynn Gildea Prof Greg Rubin

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Contents

Acknowledgements 4

Contact details 4

Executive Summary 5

1.0 Background and literature review 9

2.0 Methods 13

2.1 Qualitative evaluation 13

2.2 Analysis of routinely collected data 13

3.0 Quantitative Analysis (Early diagnosis metrics) 14

3.1 Introduction 14

3.1.1 CRUK Facilitator areas 14

3.1.2 Interventions 14

3.1.3 Aim 15

3.1.4 Data source 15

3.1.5 Authors 12

3.2 Methods 15

3.2.1 Data source and metrics 15

3.2.2 Practices included and excluded 15

3.2.3 Data periods 16

3.2.4 Cancer sites 17

3.2.5 Statistical methods 17

3.3 Clinical Commissioning Group and practice level changes 17

3.4 All practices trend 17

3.4.1 All cancers – Referral rate 18

3.4.2 All cancers – Conversion rate 20

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3.4.3 All cancers – Detection rate 22

4.0 Qualitative Analysis - Interviews 25

4.1 Perceptions of the role 25

4.2 Deviation from the role 29

4.3 Changes/barriers to effective working 30

4.4 Key Facilitator behaviours 32

4.4.1 Expertise 32

4.4.2 Leadership and impact 35

4.4.3 Scope of influence 38

4.4.4 Influence on wider cancer work 38

4.4.5 Resource management 39

4.4.6 Future of the role 40

5.0 Discussion 42

5.1 Key responsibilities 43

5.2 Key behaviours and competencies 43

5.2.1 Expertise 43

5.2.2 Leadership and impact 44

5.2.3 Resource management 44

5.3 Challenges 44

5.4 Strengths and weaknesses 45

5.5 Conclusions 45

5.6 Recommendations 45

6.0 References 47

7.0 Glossary 48

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Appendix 1 Ethics approval 49

Appendix 2 Statistical methods 50

Appendix 3 Additional analyses 51

1.0 Group level rates 51

1.1 Lung cancer - Referral rate 51

1.2 Lung cancer – Conversion rate 52

1.3 Lung cancer – Detection rate 54

1.4 Colorectal cancer – Referral rate 56

1.5 Colorectal cancer – Conversion rate 57

1.6 Colorectal cancer – Detection rate 59

2.0 Practice level changes 61

2.1 All cancers – Referral ratio 61

2.2 All cancers – Conversion rate 63

2.3 All cancers - Detection rate 66

2.4 Lung cancer - Referral ratio 69

2.5 Lung cancer- Conversion rate 72

2.6 Lung cancer – Detection rate 75

2.7 Colorectal Cancer – Referral ratio 78

2.8 Colorectal Conversion Rate 81

2.9 Colorectal cancer – Detection Rate 84

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Acknowledgements

We thank everyone who agreed to share their time, opinions and experiences with us as part of the

evaluation.

This evaluation would not have been possible without the support of the CRUK Facilitators

themselves, who were key to identifying potential informants for this evaluation.

Contact information:

Dr Ingrid Ablett-Spence

Evaluation, Research and Development Unit,

School of Medicine, Pharmacy and Health,

Durham University,

Queens Campus,

Stockton-on-Tees,

TS17 6BH.

Tel: 0191 3340309.

Email: [email protected]

mailto:[email protected]

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Executive Summary

Background

In 2012/13, funding was allocated by Cancer Research UK (CRUK) to support the introduction of

primary care facilitators in a limited number of cancer networks, as part of the NAEDI / Cancer

Networks Supporting Primary Care initiative. These facilitators would provide additional capacity and

expertise to the initiative. Specifically, they would provide support, advice and training to General

Practices on cancer issues with a particular focus on supporting practices to adopt actions which

promote earlier diagnosis of cancer. They were expected to work closely with their local NHS Clinical

Commissioning Group (CCG), GP Cancer Leads and cancer network.

Six facilitators were recruited, three in the Merseyside and Cheshire Cancer Network (8 (or 9) CCGs)

and three in the North Central London and West Essex Cancer Commissioning Network (3 CCGs).

Five of the six came into post by January 2013; the sixth took up post in August 2013.

Methods

This evaluation used a mixed methods approach. Qualitative interviews with GPs, practice managers

and commissioners explored the value to them of the facilitator role. We also analysed the impact of

facilitators on referral practice. Efficient use of the urgent referral pathway for suspected cancer, as

determined by conversion and detection rates, is generally accepted as a quality marker for cancer

diagnosis in primary care. We expected that, by increasing uptake of quality improvement measures

amongst others, facilitators would have a positive and measurable effect on these metrics. Using

Cancer Waiting Times data, we compared CCGs served by facilitators with comparable CCGs and,

within these, the reach and impact on referral metrics of four activities (practice plans, audit,

significant event analysis, use of risk assessment tools) considered to have an early effect on referral

practice. We compared a period before the Supporting Primary Care initiative (April 2009-March

2010) with the first 12 months that the Facilitators were in post (January 2013-December 2013).

Findings

We found that Facilitators make a practical difference by providing increased capacity; providing

additional support to GP practices and to GP Cancer Leads; signposting practices to areas of other

support; providing a project management function to facilitate the completion of tasks.

They make a wider difference as well, by influencing strategies, including JSNAs and Commissioning

plans, and by working in partnership with GP Cancer Leads, Public Health, CCG Commissioners and

secondary care colleagues. They are raising awareness of the importance of early diagnosis across a

range of clinical areas. Lastly, they are encouraging practices to review their performance and

supporting the development of action plans to address areas for improvement.

Facilitators appear to continue to be very effective at engaging with general practices but there is

still no way of knowing whether this is due to the additional capacity they bring above that of a GP

Cancer Lead or whether it is due to their individual personalities and tenacious approach.

The level of uptake of the four specified activities in Facilitator CCGs was almost double that in

comparator CCGs (69% vs 36%). Against a background of significant increases in referral, conversion

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and detection rates between the two periods, the facilitator CCGs and comparator CCGs differed at

both baseline and follow-up. However, there was, in general, a greater reduction in the degree of

variation in these metrics between practices in Facilitator CCGs, compared to those in comparator

CCGs.

In general and considering all cancers as well and lung and colorectal cancer specifically, Facilitator

CCGs had higher referral and detection rates, and a lower conversion rate, than comparator CCGs at

baseline but by the end of the first year of facilitator input, this gap had narrowed rather than being

maintained.

For facilitator and comparator CCGs combined, there was a statistically significant 37%

increase in referral rates for all cancers, from 1,985 to 2725 per 100,000 population. There

were also significant increases in suspected lung and colorectal cancer referral rates of 29%

(from 92 to 119) and 41% (from 319 to 450), respectively.

Conversion rates decreased significantly over the two time periods for all cancers and for

lung and colorectal cancer individually: all cancers by -1.7 percentage points (from 10.6% to

8.9%); colorectal cancer by -1.1 percentage points (from 6.0% to 4.8%); lung cancer by -4.1

percentage points (from 27% to 23%).

Detection rates increased significantly over the two time periods for all CWT-recorded

cancers combined and for lung and colorectal cancer individually: lung cancer by 5.8

percentage points (from 37% to 42%); colorectal cancer by 3.5 percentage points (from 34%

to 37%).all CWT-recorded cancers by 4 percentage points (from 44% to 48%).

Overall, 53% of all included GP practices were involved in at least one NAEDI intervention of interest,

namely practice plans, clinical audit, significant event analysis, use of risk assessment tools (RATs) ;

with 13% of practices using RATs. In CRUK Facilitator areas, more practices were involved in at least

one intervention (69% of practices, compared to 36% in Comparator areas) but fewer practices were

recorded as using RATs (8%, compared to 19%).

In CCGs served by CRUK Facilitators, the increase in referral rates (35%) was significantly

smaller than for Comparator CCGs increase (40%), although the referral rate remained

significantly higher in Facilitator CCGs.

There was no significant difference between the Facilitator and Comparator CCGs in changes

in conversion rate, which decreased by less than 2 percentage points in both groups.

The increase in detection rate was significantly larger for Comparator CCGs (6 percentage

points) than for the Facilitator CCGs (2 percentage points). However, the detection rate was

significantly higher for the CRUK Facilitator CCGs, at 49%.

For practice conversion rates, the percentage point decrease in interquartile range between

the before and after periods was larger for the Facilitator CCGs, compared to the

Comparator CCGs (-2.1 vs -1.6).

For practice detection rates, the percentage point decrease in interquartile range was larger

for the Facilitator CCGs compared to the Comparator CCGs (4.3 vs 2.3).

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Changes in referral metrics attributable to use of risk assessment tools are reported in an

appendix only, since the number of user practices was small.

In interpreting these findings, several points should be made:

Change in referral, conversion and detection rates are unlikely to be linear. For example,

there is a ceiling effect for detection rate, with the ‘best’ 10% of practices in England

achieving a figure of around 60%. A similar effect is seen for conversion rate and can be

anticipated for referral rate. This means that the scope for further improvement reduces,

both in absolute terms but also relative to a comparator group.

Referral metrics for the group of Facilitator CCGs differed from those for England at baseline,

with a referral rate that was 48% higher, a conversion rate 11% lower and a detection rate

7% higher.

Referral metrics for the group of Comparator CCGs also differed from those for England at

baseline, with a referral rate that was 27% higher, a conversion rate 5% lower and a

detection rate 7% lower.

The choice of outcome measures for this facilitator initiative was limited by the time

available, the type of initiatives being promoted to practices through facilitators, the

feasibility of collecting robust measures and the resources available. Two week wait referral

metrics are measures of process only indirectly related to outcomes such as stage at

diagnosis or survival. Neither does the CWT dataset capture all cancer diagnoses.

Nevertheless these data reflect the generality of cancer diagnosis are an increasingly

accepted proxy for quality of cancer referral practice.

The activity in the two 12-month periods of observation for this study permits limited

analysis because of small numbers. For example, emergency presentation rates were not

examined for this reason. Data on the use of risk assessment tools is provided in the

appendix, but the activity levels were low and the results should be viewed with caution.

There were higher levels of exclusion than in previous reports of the NAEDI Supporting

Primary Care initiative. This was primarily because of significant changes in practice list size.

The key benefits of Facilitators have been previously identified as providing increased capacity,

providing additional support to GPs and to GP cancer leads, signposting to other sources of support

and providing a project management function. We found that they now, and in addition, play an

influencing role in commissioning, have a strong partnership working function and have facilitated

practices in their use of data to inform action plans. However, they face challenges in maintaining

impetus among practices around awareness and early diagnosis.

Conclusions and recommendations

In this pilot, facilitators were introduced in a small number of localities within two cancer networks.

Their impact has been positive at both practice and CCG level, with almost double the number of

practices being involved in one or more of three specified activities. They have had an effect on

referral metrics, notably by reducing variation in practice. Other effects, on conversion and

detection rates, are less clear and may reflect a ‘ceiling’ effect or selection bias, with facilitators

being taken up by CCGs that were already performing comparatively well compared to the rest of

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England, and certainly in comparison to equivalent CCGs. The future model for supporting primary

care improvement in cancer diagnosis may need to evolve if practices are to embed such activities

into their organisational culture rather than treat them as time-limited projects.

Our findings indicate that facilitators are most effective as agents of change at practice and CCG

level, rather than simply taking data to practices and explaining it. Given that this initiative was

supported by short-term charitable funding, their continued impact presupposes CCGs buy into the

model.

Our recommendations are that:

1. This model of facilitation was acceptable and effective at both practice and CCG level. The

skill set and approach taken were broadly generic and would readily adapt to other disease

areas. CCGs should consider its adoption as a means of influencing quality improvement.

2. In order for a facilitation model of this type to become embedded, a sustainable funding

stream should be identified. Some progressive transition from the current arrangement to

NHS funding is necessary.

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1.0 Background and literature review

The National Awareness and Early Diagnosis Initiative (NAEDI) was launched in 2008 in order to

understand and address the reasons for late diagnosis of cancer in England. In 2010 a model for GP

Leadership was established within Cancer Networks to support NAEDI initiatives in primary care. The

2011/12 activity for local improvement and GP leadership included a range of projects in Cancer

Networks across England, the evaluation of that work programme showed that where GP practices

engaged in one of more of the promoted activities (designed to increase awareness and earlier

diagnosis) outcomes were improved, (Ablett-Spence, Howse and Rubin, 2012). In 2012/13 the

Department of Health and National Cancer Action Team ( NCAT) Supporting Primary Care work

programme focused on continuing key activities in primary care. Cancer Research UK (CRUK)

developed the concept of Primary Care Facilitators, who would provide additional capacity and

expertise, and support the implementation of change in primary care settings. Funding was allocated

by them to support the introduction of facilitators in a limited number of cancer networks. This

initiative was undertaken in close collaboration with the National Cancer Action Team, who retained

overall responsibility for the Supporting Primary Care initiative.

This evaluation extends the initial evaluation of the CRUK Facilitator role contained within the wider

report on NAEDI/Cancer Networks supporting primary care (Ablett-Spence, Howse, Gildea and

Rubin, 2013). In that report we focussed on the Facilitators’ perceptions of the role and how they

supported primary care to improve cancer awareness and early detection rates, as well as

identifying the contexts and mechanisms which supported the implementation of key activities. The

2014 evaluation focuses on the experience of GPs, Practice Managers and Commissioners who

engaged with the initiative.

Facilitation is the process of providing support to individuals or groups to achieve beneficial change.

It has been described as “the provision of opportunity, resources, encouragement and support for

the individual or group to succeed in achieving their objectives and to do this through enabling them

to take control and responsibility for the way they proceed,” (Bentley, 1994). Other definitions

include facilitators being defined as a “catalyst for change” and as someone who “helps forward and

gives direction by drawing on their own experience,” (Petrova et al, 2010). The literature suggests

that key attributes of Facilitators include knowledge of the topic area, skills and techniques for

structuring and driving a process of change and in some instances expertise in the clinical area

addressed by the intervention.

The Cochrane Collaboration review on educational outreach visits: effects on professional practice

and health care outcomes concluded that educational outreach visits can be effective in improving

practice in the majority of circumstances, but that the effect is variable (O’ Brien et al, 2008). The

review also suggested that effects for the most part are small to moderate but potentially important.

It is not known to what extent performance is likely to deteriorate or improve over time, or whether

multiple visits are more beneficial. The cost and cost effectiveness of this approach will depend upon

targeted behaviours and the context in which the interventions are provided. McGowan et al (1997)

and Petrova et al (2010) also confirm the difficulty in assessing the long term and outcome related

effects of facilitated interventions as well as uncertainty as to which aspects of the facilitators’ role

and approach are most effective in stimulating a change in practice. Petrova et al (2010) suggest that

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this is unsurprising given that most of the published studies involve small numbers of facilitators

which precludes comparison between different approaches and facilitator profiles.

Facilitated interventions have been used in primary care settings since the 1980s (Petrova et al,

2010). However the current evidence base relating to Primary Care facilitators does not reflect the

way primary care is currently organised, nor does it include a specific focus on cancer awareness and

early diagnosis. Primary care facilitators have been used in a number of countries as a resource to

support the increasing complexity of primary care (Nagykaldi et al., 2005). They have been identified

as an effective way of changing practice within primary care and have been used to increase

prevention and change practice with regards to cancer, cardiovascular disease, diabetes, mental

health, asthma and end of life care (Nagykaldi et al., 2005; Hogg et al., 2008).

One of the main functions of the CRUK Facilitators is to visit General Practices in order to provide

support, advice and training on cancer issues with a particular focus on supporting practices to adopt

actions which promote the earlier diagnosis of cancer. As long ago as 1989 the value of educational

outreach visits were identified as having the potential to change health professional practice

(Soumerai, 1989). The term educational outreach is used to describe a personal visit by a trained

person to health professionals in their own settings.

Where Facilitators have been utilised, multifaceted approaches have been used to provide primary

care with clinical and non-clinical support to improve cancer outcomes such as professional

educational materials, clinical audit, operational systems improvement and implementation of

clinical guidelines or relevant information technology (Nagykaldi et al, 2005).

The activities performed by primary care facilitators vary greatly. Those occurring most often in

reports relating to facilitated interventions in primary care include; auditing practice processes and

feeding back the findings; facilitating discussions, consensus building, planning and responsibility

allocation; providing training and sharing information and helping practices develop reminder

systems, protocols and data collection forms. In terms of effectiveness, multi-faceted interventions

employing trained individuals who meet with practitioners in their practices have been shown to be

more effective in introducing changes in primary care than any other single intervention, (Hogg et al,

2002).

The NAEDI programme funded Facilitators in one geographical area to promote awareness and early

diagnosis initiatives in General Practice, this initiative informed the development of the CRUK

Facilitator role. CRUK subsequently took over the roles initially funded by NAEDI and initiated

the pilot by appointing a further 3 Facilitators in another area (one of these posts is managed by

CRUK but funded by the local Public Health team).

Table 1 – Pilot site Cancer Network areas and CCGs within them

Cancer Network Area CCGs Commencement of facilitators

Merseyside and Cheshire Cancer Network

Southport and Formby Liverpool Wirral Western Cheshire South Sefton Warrington

*October 2011 August 2012 *October 2011

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Halton St Helens

*funded by CRUK from April 2013

North Central London and West Essex Cancer Commissioning Network

Enfield Islington Waltham Forest

August 2013 January 2013 October 2012

The main purpose of the CRUK Facilitator role as defined in the job description is:

“To provide support, advice and training to all General Practices on cancer issues with a particular

focus on supporting practices to adopt actions which promote earlier diagnosis of cancer. The post

holder will work closely with the local NHS Clinical Commissioning Group, GP Cancer Leads and the

cancer network to deliver the objectives as outlined in the Primary Care Engagement Programme, in

addition to supporting other local cancer earlier diagnosis projects.”

The Facilitators were to be part of the CRUK General Practice Engagement and Support Team and

were to be supported to develop the necessary skills and knowledge to deliver the required

outcomes and contribute to learning events. They were to work closely with NHS Clinical

Commissioning Groups (CCGs) to build upon work previously done with GPs and primary care

relating to early diagnosis and to support engagement with the primary care population.

Facilitator key responsibilities:

Build effective relationships with and actively engage all GP practices within the locality to:

- Raise the awareness of the importance of early diagnosis

- Support practices in the analysis and interpretation of Practice Profiles, in addition to other

cancer statistics

- Encourage practices to undertake RCGP cancer audit/significant event audits

- Promote the use of cancer decision aids such as Risk Assessment Tools (RAT)

- Share best practice and developments relating to cancer and primary care

- Understand and evaluate current practice systems and processes

- Ultimately, negotiate appropriate tailored action plans and solutions which promote the

earlier diagnosis of cancer, cancer awareness and prevention

Maintain regular communication with all practices and provide ongoing specialist support to

practices, to adopt earlier diagnosis interventions

Develop, plan and co-ordinate learning events for primary care professionals to enhance

knowledge of cancer early signs and symptoms, prevention, screening and interventions that

promote earlier diagnosis. Where appropriate, design and provide bespoke training sessions

for practice staff

Facilitate relationships between primary and secondary care health professionals through

the development of joint clinical forums and education events to share knowledge, discuss

case studies and service development

Lead and co-ordinate practice improvement projects, working with key people in general

practice and across different organisations in the local community to achieve pilot objectives

and ensure changes are embedded and sustained. This will include:

- Supporting CCGs to embed early diagnosis of cancer, pilot activities and learnings into the

CCG work programme and cancer strategies

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- Initiating contacts with public health, local authorities and key cancer partners

Contribute to the evaluation of the pilot, including:

- Developing and maintaining a comprehensive database which records pilot measures

- Reflecting on observations and analysing complex information, identify trends, opportunities

and challenges, and best practice to feedback to CRUK and other external stakeholders

- Providing monthly progress reports

- Provide reports and information to NHS partners and collaborating organisations

- Participating in and providing information for internal and external research studies

Keep up to date and share with internal and external stakeholders, quality information on

early diagnosis initiatives, cancer signs and symptoms and any developments relating to

primary care and cancer

Provide support to fellow CRUK Primary Care Engagement team members, including sharing

of good practice, shadowing, assisting at events and developing resources

Participate in other activities and projects within the Primary Care Engagement work stream

and wider department as required

Assist in implementing other related key projects within the locality as appropriate

Key behaviours and competencies detailed in the job description fall within the following headings:

Expertise including communication, facilitation and influencing skills, the ability to develop tailored

solutions/action plans and lead on their implementation.

Leadership and Impact, including the ability to prioritise and manage multiple projects. The ability to

be flexible and adapt to different settings was also essential.

Resource management, requiring organisational and project management skills, the ability to

understand, interpret and present complex data in a clear manner.

The job description also required the Facilitators to have experience of working within the NHS with

primary care and general practice and to have had experience of working with multiple stakeholders

across organisational boundaries. They were also required to have project management skills,

experience of evaluation and audit methodologies, knowledge of service improvement

methodologies and tools, knowledge of medical terminology and a good understanding of cancer

awareness and early diagnosis related issues.

Evaluation of the role

This evaluation focuses on the two initial pilot sites, one in the South East and one in the North West

of England. CRUK Facilitators in these areas are aligned to CCG areas and work with the individual GP

practices within them. All of their work is with Commissioners, GPs and their staff; there is minimal

direct interaction with patients and this was not considered as part of the evaluation.

Aims

To determine the impact that CRUK Facilitators have in supporting primary care.

Secondary Objectives

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To determine the response of GPs, Practice Managers and Commissioners to the implementation of

the facilitator role.

To identify changes implemented as a result of working with a CRUK Facilitator.

2.0 Methods

This evaluation used a mixed methods approach.

2.1 Qualitative evaluation

The qualitative element of this evaluation utilised telephone interviews with GPs, Practice Managers

and Commissioners involved in the provision of cancer awareness information and diagnoses of

cancer in primary care.

An interview schedule was developed, informed by a review of literature relating to Facilitators in

primary care and by previous research commissioned by the National Cancer Action Team (NCAT) to

evaluate the Supporting Primary Care initiatives was developed.

The interviews were recorded and transcribed and Framework analysis was used to analyse the data,

(Srivastava & Thomson, 2009).Framework analysis is grounded or generative i.e. it is based in and

driven by the original accounts and observations of the people it is about.

The CRUK Facilitators were responsible for identifying potential subjects for interview. They visited

potential participants to discuss the evaluation and provide information sheets and consent forms.

Completed consent forms were then forwarded to the research team by the potential participants.

The research team then selected participants, ensuring that each professional group was

represented and that each person interviewed had had contact with one or more of the facilitators.

This method of recruitment was chosen as it was the most practical in the time available and given

we needed to approach people who had had experience of working with the facilitators. There is

potential for recruitment bias with this approach and we tried to mitigate against this by having

completed forms sent to us and then selecting a cross section of people to be interviewed from a list

of all those who had consented.

Ethical approval was received from the School of Medicine, Pharmacy and Health ethics

subcommittee (Appendix 1).

2.2 Analysis of routinely collected data

In collaboration with East Midlands Knowledge and Intelligence Team, Cancer Waiting Times data on

urgent referrals for suspected cancer were collected and analysed. This quantitative analysis

considers Cancer Waiting Times (CWT) data, in order to assess how some of the NAEDI initiatives to

support primary care have affected referral practices, with a particular focus on the impact of CRUK

Facilitators. The methods used are fully described in Chapter 3.

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3.0 Report of Quantitative Analysis (Early Diagnosis Metrics)

3.1 Introduction

3.1.1 CRUK Facilitator Areas

This analysis initially compares those areas with CRUK Facilitators to some suitable Comparator

areas. A list of the CCGs which the CRUK Facilitators worked with was provided. This was then used

to construct a group of Comparator CCGs. For each CRUK Facilitator CCG, similar CCGs were

identified according to existing CCG classification groups1, which are based on age structure, ethnic

mix, population density and deprivation, along with the latest QOF information on the number of

practices and total population. The final group of Comparator CCGs was selected to maximise the

similarity between the CRUK Facilitator areas and Comparator areas, in terms of the number of

practices, total population and average list size. Table 2 provides a list of the CRUK Facilitator and

selected Comparator CCGs, with a comparison of practices and total population.

Table 2: List of CRUK Facilitator CCGs and Comparator CCGs, with comparison of number of practices

and total population

3.1.2 Interventions

Within the CRUK Facilitator and Comparator areas, this analysis considers further differences in

terms of whether practices used some of the specific interventions. It particularly considers three of

the interventions hypothesised to have an earlier impact on referral practice:

- Practice plans

- Audit (two types: CBA [criterion based audit] and SEA [significant event analysis])

- Risk assessment tools (RATs)

Cancer networks provided information on the types of interventions used in their GP practices. For

practices within the CRUK Facilitator areas, this information was also updated by the CRUK

facilitators.

1 http://www.yhpho.org.uk/resource/browse.aspx?RID=176577

CCGNumber of

Practices

Total

PopulationCCG

Number of

Practices

Total

Population

Number of

Practices

Total

Population

NHS Southport and Formby CCG 20 122,205 NHS Rushcliffe CCG 16 121,809 4 396

NHS Liverpool CCG 95 496,221 NHS Sandwell and West Birmingham CCG 106 539,982 -11 -43761

NHS Wirral CCG 60 331,149 NHS Bromley CCG 46 331,498 14 -349

NHS West Cheshire CCG 37 255,190 NHS Lincolnshire East CCG 30 242,313 7 12877

NHS South Sefton CCG 33 155,077 NHS South Tyneside CCG 29 154,490 4 587

NHS Knowsley CCG 31 161,070 NHS Thurrock CCG 34 164,031 -3 -2961

NHS Warrington CCG 26 208,856 NHS Gateshead CCG 34 206,317 -8 2539

NHS Halton CCG 17 128,620 NHS Ashford CCG 15 122,614 2 6006

NHS St Helens CCG 37 193,391 NHS Sutton CCG 28 186,778 9 6613

NHS Enfield CCG 53 307,950 NHS Hounslow CCG 54 289,992 -1 17958

NHS Islington CCG 37 229,211 NHS West London (K&C & QPP) CCG 55 229,080 -18 131

NHS Waltham Forest CCG 45 296,070 NHS City and Hackney CCG 44 291,870 1 4200

Total CRUK Facilitator CCGs 491 2,885,010 Total Comparator CCGs 491 2,880,774 0 4236

Average list size

CRUK Facilitator CCGs Comparator CCGs Differences

5875.8 5867.2 -8.6

http://www.yhpho.org.uk/resource/browse.aspx?RID=176577

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3.1.3 Aim

The analysis investigates differences between the CRUK Facilitator and Comparator areas, and by

intervention groups, in terms of the cancer waiting times metrics; referral rates, conversion rates

and detection rates. Comparisons are made against the national average for two periods; the before

interventions period, from April 2009 to March 2010, and the after period, from January-December

2013.

3.1.4 Data Source

Cancer Waiting Times data was obtained from the National Cancer Waiting Times Monitoring

Dataset, provided by NHS England.

3.1.5 Authors

This section of the report was compiled by Public Health England’s National Cancer Intelligence

Network (NCIN), operated by Public Health England.

The NCIN was established in June 2008 to coordinate the collection, analysis and publication of

comparative national statistics on diagnosis, treatment and outcomes for all types of cancer. The

NCIN is a UK wide partnership funded by multiple stakeholders. The NCIN will drive improvements in

the standards of care and clinical outcomes through exploiting data. The NCIN will support audit and

research programmes by providing cancer information and patient care will be monitored through

expert analyses of up-to-date statistics. www.ncin.org.uk and www.gov.uk/phe

3.2 Methods

3.2.1 Data Sources and Metrics

Cancer Waiting Times (CWT) data, provided by NHS England, are used to obtain the number of

urgent GP referrals for all suspected cancers from April 2009 - December 2013, based on “Date First

Seen”, and the number of cancers receiving a first treatment during the same period, based on

“Treatment Start Date”. These figures are used to calculate referral rate, conversion rate and

detection rate, which are defined as:

- Referral rate (number of urgent GP referrals relative to list size)

- Conversion rate (percentage of urgent GP referrals resulting in a cancer diagnosis)

- Detection rate (percentage of CWT recorded cancers resulting from an urgent GP referral)

For the detection rates included in this report, it is important to note that the rates are not based on

a complete record of all cancer registrations. The detection rate is based only on cases recorded in

the CWT data.

3.2.2 Practices Included and Excluded

Based on 2009/10 and 2012/13 QOF list sizes and Attribution Dataset (ADS) populations from 2009

and 2013, practices with significant changes in practice list size (eg. closure or merger) were

excluded from the analyses. Practices with list sizes of less than 1000 were also excluded. Of all

practices in the facilitator and comparator CCGs, 319 that were present in the 2009/10 QOF dataset

were removed from the analysis; 120 of these had an audit, practice plan or risk assessment tool

http://www.ncin.org.uk/

http://www.gov.uk/phe

16

intervention. A further 18 were excluded because they were not in the 2009/10 QOF dataset, 3

practices with a recorded intervention.

The commonest reason for exclusion of practices was significant change in practice population

(between 77% and 88% of all exclusions in each group). This was accounted for 116 of the 145

practices in comparator CCGs that had not taken up any NAEDI initiative. Of those practices excluded

because of small list size, 5/16 in facilitator CCGs had taken up a NAEDI intervention, and only 1/16

in comparator CCGs.

All practices were grouped according to the combination of intervention types used, as follows:

Table 3: GP practice groups, according to combinations of intervention(s), with number of GP

practices in each intervention group

Table 3: Outcomes – Distribution of practices by uptake of NAEDI interventions in facilitator/comparator CCGs

CCG GroupPractice

Group

Practice

plans

Existing

audit

SEA

audit

Risk

assessment

tool

Number

of

Included

Practices

Number of

Excluded

Practices

(In QOF

09/10)

Number of

Excluded

Practices

(Not in QOF

09/10)

%

Included

Any

intervention240 79 3 74.5

No

interventionNo No No No 110 64 5 61.5

Y - RAT - - - Yes 28 11 0 71.8

Z - no RAT - - - No 322 132 8 69.7

350 143 8 69.9

Any

intervention112 40 0 73.7

No

interventionNo No No No 201 135 10 58.1

Y - RAT - - - Yes 61 23 0 72.6

Z - no RAT - - - No 252 152 10 60.9

313 175 10 62.9

CRUK

Facilitator

CCGs

AT LEAST ONE YES

Comparator

CCGs

AT LEAST ONE YES

Overall, 53% of all included GP practices were involved in at least one type of included intervention;

with 13% of practices using RATs. In CRUK Facilitator areas, more practices were involved in at least

one intervention (69% of practices, compared to 36% in Comparator areas) but fewer practices were

recorded as using RATs (8%, compared to 19%).

3.2.3 Data Periods

The analysis considers two periods; the before interventions period and after period; these periods

were taken as April 2009 to March 2010 and January 2013 to December 2013, respectively. These

periods are not exclusively before uptake and after completion of all interventions, but are as close

as possible considering the available data; a number of audits were started and some completed

17

prior to March 2010, but this is the earliest year of useable CWT data as prior to this the data was

collected in a different way or was incomplete. Additionally, it is possible that some interventions

only commenced towards the end of the data period, however it is cannot be determined which

were and were not completed earlier than this.

3.2.4 Cancer Sites

Analysis of GP practices by intervention group considers referrals and diagnoses for all cancers. As

the RAT intervention specifically relates to colorectal and lung cancers, analysis by the RAT

intervention group considers referrals and diagnoses for lung and colorectal cancers.

Please note that some of the practice level rates in this report are based on very small numbers and

so these results should be interpreted with caution. This is particularly true for detection rates for

individual cancers sites.

3.2.5 Statistical methods

See appendix 2 for a full description of the statistical methods employed.

3.3 Clinical Commissioning Group and practice-level changes

The key findings from analyses at the level of the group, CCG and general practice are now

presented. A more detailed set of analyses is provided in Appendix 3.

3.4 All practices trend

Between April 2009-March 2010 and January-December 2013, there was a statistically significant

37% increase in referral rate for all cancers in the combined population of facilitator and comparator

CCGs, from 1,985 per 100,000 population to 2,725. There was also a smaller, significant increase in

the lung cancer referral rate of 29% (from 92 to 119) and a larger increase in the referral rate for

suspected colorectal cancer of 41% (from 319 to 450).

Conversion rates decreased significantly between the two time periods for all three site groups. The

decrease for all cancers was 1.7 percentage points (from 10.6% to 8.9%). There was a larger

decrease of 4.1 percentage points (from 27% to 22.9%) for lung cancers and a smaller decrease for

colorectal cancer (1.1 percentage points), from 6.0% to 4.8%.

Detection rates increased for all CWT recorded cancers by 4 percentage points, from 43.9% to

47.8%. There was also a larger significant increase for CWT recorded lung cancers of 5.8 percentage

points (from 36.6% to 42.4%) and a smaller increase of 3.5 percentage points (from 33.8% to 37.3%)

for CWT recorded colorectal cancers.

Table 4: Comparison of referral, conversion and detection rates, all included GP practices, from

before to after intervention periods, by cancer site

18

Note: Referral rate is the directly age-standardised referrals rate per 100,000 person population

Over a similar period (the 12 months to March 2010 and to March 2013), the all-England referral

rate rose by 29%, from 1438 to 1856 / 100,000. The conversion rate fell from 11.4% to 10.2% and

the detection rate rose from 43.9% to 47.8%. For lung cancer the all-England referral rate rose by

32% to 71/100,000, the conversion rate fell by 4.5 points to 24.3% and the detection rate rose by 2.1

points to 41.8%. For colorectal cancer, the all-England referral rate rose by 48% to 300 / 100,000, the

conversion rate fell 1.9 points to 5.6% and detection rate rose 2.4 points to 40.1%.

3.4.1 All Cancers - Referral Rate

There were statistically significant increases in referral rates from the before to after intervention

periods for both the CRUK Facilitator CCGs and the Comparator CCGs (Table 5). The CRUK Facilitator

CCGs had statistically significantly larger referral rates than the Comparator CCGs in both the before

and after intervention periods. However, the Comparator CCGs had a statistically significantly larger

increase of 40%, compared to 35% for the CRUK Facilitator CCGs.

Table 5: Comparison of referral rates for CRUK Facilitator CCGs and Comparator CCGs, from before to

after intervention periods, all cancers


Figure 1: Comparison of referral rates for CRUK Facilitator CCGs and Comparator CCGs, from before

to after intervention periods, all cancers

Total LCL UCL Total LCL UCL

Referral Rate 1,985.2 1,970.4 2,000.0 2,725.4 2,708.5 2,742.3 37.3% 36.0% 38.6% <0.001

Conversion Rate (%) 10.6 10.4 10.8 8.9 8.7 9.1 -1.7 -2.0 -1.4 <0.001

Detection Rate (%) 43.9 43.2 44.6 47.8 47.1 48.6 4.0 2.9 5.0 <0.001

Referral Rate 92.1 88.8 95.4 119.0 115.4 122.7 29.3% 23.3% 35.5% <0.001

Conversion Rate (%) 27.0 25.4 28.6 22.9 21.7 24.2 -4.1 -6.1 -2.1 <0.001

Detection Rate (%) 36.6 34.7 38.6 42.4 40.4 44.4 5.8 2.9 8.6 <0.001

Referral Rate 318.7 312.7 324.8 449.9 442.9 457.0 41.2% 37.7% 44.7% <0.001

Conversion Rate (%) 6.0 5.5 6.4 4.8 4.5 5.2 -1.1 -1.7 -0.6 <0.001

Detection Rate (%) 33.8 31.7 35.9 37.3 35.2 39.4 3.5 0.5 6.4 0.020

P-valueA

ll C

ance

rsLu

ng

Can

cer

Co

lore

ctal

Can

cer

All Included PracticesBefore After

Change LCL UCL

Referral

RateLCL UCL

Referral

RateLCL UCL

CRUK Facilitator CCGs 2,132.9 2,111.9 2,154.1 2,888.2 2,864.3 2,912.3 35.4% 33.7% 37.2% <0.001

Comparator CCGs 1,820.8 1,800.4 1,841.5 2,544.8 2,521.1 2,568.6 39.8% 37.7% 41.8% <0.001

P-value

Before After

All Cancers Change LCL UCL

19

As can be seen from Table 6, the largest, statistically significant increase in referral rates was in the

Comparator CCGs’ any intervention group (46%). This change was statistically significantly higher

than that seen in the Comparator CCGs’ no intervention group (36%) as well as the CRUK Facilitator

CCGs’ any intervention and no intervention groups, which had increases of 35% and 38%,

respectively.

Table 6: Comparison of referral rates for CRUK Facilitator CCGs and Comparator CCGs, by

intervention group, from before to after intervention periods, all cancers

Note: Referral rate is directly age-standardised rate per 100,000 person population

Figure 2: Comparison of referral rates for CRUK Facilitator CCGs and Comparator CCGs, by


Referral

RateLCL UCL

Referral

RateLCL UCL

Any intervention 2,123.1 2,098.1 2,148.2 2,850.6 2,822.4 2,879.1 34.3% 32.2% 36.4% <0.001

No intervention 2,156.6 2,117.7 2,196.0 2,979.0 2,934.2 3,024.3 38.1% 34.9% 41.4% <0.001

Any intervention 1,873.9 1,839.8 1,908.6 2,738.5 2,698.0 2,779.4 46.1% 42.7% 49.6% <0.001

No intervention 1,789.6 1,764.1 1,815.4 2,432.1 2,403.0 2,461.5 35.9% 33.4% 38.5% <0.001

P-valueAll Cancers

CRUK Facilitator

CCGs

Comparator CCGs

Before After

Change LCL UCL

20

A standardised referral ratio (SRR) was calculated for each of the GP practices in the CRUK Facilitator

CCGs and Comparator CCGs, with England as the reference geography.

Table 7: Interquartile range of standardised referral ratios, for CRUK Facilitator CCGs and

Comparator CCGs, by intervention group, from before to after intervention periods, all cancers

Figure 3: Range in standardised referral ratios, for CRUK Facilitator CCGs and Comparator CCGs, by


3.4.2 All Cancers - Conversion Rate

There were small but statistically significant decreases in the all cancers conversion rates between

the before and after intervention periods for both the CRUK Facilitator CCGs and Comparator CCGs.

The decreases were less than 2 percentage points, with no evidence of a significant difference

between the two areas (Table 8).

Table 8 Comparison of conversion rates for CRUK Facilitator CCGs and Comparator CCGs, from before


Figure 4: Comparison of conversion rates for CRUK Facilitator CCGs and Comparator CCGs, from

before to after intervention periods, all cancers

Conversion

Rate (%)LCL UCL

Conversion

Rate (%)LCL UCL

CRUK Facilitator CCGs 10.2 10.0 10.5 8.7 8.5 8.9 -1.5 -1.9 -1.2 <0.001

Comparator CCGs 11.0 10.7 11.4 9.2 8.9 9.4 -1.9 -2.3 -1.4 <0.001

UCLAll Cancers

Before After

P-valueChange LCL

21

The Comparator CCGs’ any intervention group had the largest statistically significant decrease in

conversion rate (2 percentage points) of the four intervention groups. However, there was no

evidence of any statistically significant differences in the changes between all four groups (Table 9).

Table 9: Comparison of conversion rates for CRUK Facilitator CCGs and Comparator CCGs, by


Figure 5: Comparison of conversion rates for CRUK Facilitator CCGs and Comparator CCGs, by


Conversion

Rate (%)LCL UCL

Conversion

Rate (%)LCL UCL

Any Intervention 10.6 10.3 11.0 9.0 8.7 9.3 -1.6 -2.1 -1.2 <0.001

No Intervention 9.4 8.9 9.9 8.1 7.7 8.5 -1.3 -1.9 -0.6 <0.001

Any intervention 10.9 10.3 11.5 8.8 8.4 9.2 -2.1 -2.8 -1.4 <0.001

No intervention 11.1 10.7 11.6 9.4 9.1 9.8 -1.7 -2.3 -1.2 <0.001

P-value

CRUK Facilitator

CCGs

Comparator CCGs

UCLAll Cancers

Before After

Change LCL

22

Table 10: Interquartile range of conversion rates, for CRUK Facilitator CCGs and Comparator CCGs, by


Figure 6: Range in conversion rates, for CRUK Facilitator CCGs and Comparator CCGs, by intervention

group, from before to after intervention periods, all cancers

3.4.3 All Cancers - Detection Rate

The detection rate for all cancers was statistically significantly higher in the CRUK Facilitator CCGs

(47%) than the Comparator CCGs (41%) in the before period (Table 11). Between the before and

after period, there was a statistically significant increase in both areas. However, the Comparator

CCGs had the larger increase of the two areas, of 6 percentage points, significantly larger than the

CRUK Facilitator CCGs’ 2 percentage point increase.

Table 11: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, from

before to after intervention periods, all cancers

Figure 7: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, from before


Before After Change

Any Intervention 7.6 5.4 -2.2

No Intervention 7.6 4.8 -2.8

Any Intervention 6.8 7.3 0.4

No Intervention 8.1 5.7 -2.4

All Cancers

CRUK Facilitator CCGs

Comparator CCGs

Detection

Rate (%)LCL UCL

Detection

Rate (%)LCL UCL

CRUK Facilitator CCGs 46.8 45.8 47.8 48.8 47.8 49.8 2.0 0.6 3.4 0.006

Comparator CCGs 40.8 39.8 41.9 46.7 45.7 47.8 5.9 4.5 7.4 <0.001

All Cancers

Before After

Change LCL UCL P-value

23

It can be seen from Table 12 that the detection rates in the CRUK Facilitator CCGs’ any and no

intervention groups were statistically significantly higher than rates in the two groups for the

Comparator CCGs. However, in the after period there was no significant difference between the

groups, with the Comparator CCGs’ any intervention group having the highest, statistically significant

increase in detection rate (7 percentage points). This change was statistically significant larger than

the CRUK Facilitator CCGs’ any intervention group’s increase of 2 percentage points.

Table 12: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, by


Figure 8: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, by


Detection

Rate (%)LCL UCL

Detection

Rate (%)LCL UCL

Any Intervention 47.2 46.0 48.5 49.0 47.9 50.2 1.8 0.1 3.5 0.036

No Intervention 45.7 43.7 47.6 48.2 46.4 50.0 2.6 -0.1 5.2 0.059

Any Intervention 39.9 38.2 41.6 46.8 45.1 48.5 6.9 4.5 9.2 <0.001

No Intervention 41.4 40.1 42.7 46.7 45.4 48.0 5.3 3.5 7.2 <0.001

CRUK Facilitator

CCGs

Comparator CCGs

All Cancers

Before After


24

Table13: Interquartile range of detection rates, CRUK Facilitator CCGs and Comparator CCGs, for

before and after intervention periods, all cancers

Figure 9: Range in detection rates, CRUK Facilitator CCGs and Comparator CCGs, for before and after

intervention periods, all cancers

All Cancers Before After Change

CRUK Facilitator CCGs 22.1 17.8 -4.3

Comparator CCGs 20.6 18.2 -2.3

25

4.0 Qualitative analysis - Interviews

In our 2012/13 evaluation of the NAEDI Supporting Primary Care initiative we considered the CRUK

Primary Care Pilot from the perspective of those Facilitators who were in post at the time. This was

done primarily through a series of up to three 1:1 interviews with each facilitator. We found that

face to face engagement was an effective method of facilitating change (Ablett-Spence, Howse,

Gildea and Rubin, 2013). Clinicians working alongside the facilitators in 2013 suggested they valued

the roles but this was not formally studied at that time. This evaluation explored the value of the

Facilitator role to their GP, Public Health and CCG commissioning colleagues and sought to identify

specific examples of change implemented as a direct result of working with a Facilitator. However, it

needs to be acknowledged that funding arrangements, the number of post holders and some of the

individuals in post differ from when the 2012/13 evaluation commenced.

1:1 telephone interviews were conducted with 18 health care professionals from a variety of

backgrounds (as detailed in table 59). The interviews were carried out between April and June 2014.

Table 14

Professional role Number of interviews undertaken

General Practitioner (GP) 8

Practice Nurse 1

Practice Manager 2

Public Health Lead 3

CCG Commissioner 4

Total 18

Interviews lasted between 15 and 50 minutes, with the majority lasting around 20-30 minutes.

The interviewees were evenly split between the pilot sites.

GPs accounted for the majority of individuals interviewed though 6 of them were also cancer lead

GPs or had other CCG leadership responsibilities and one GP had additional practice leadership

responsibilities. These interviewees tended to bring more than one perspective to the interview.

The Practice Nurse interviewed also had additional CCG leadership Responsibilities.

4.1 Perceptions of the role

All of the informants had worked with a Facilitator in some capacity. For some, contact had been

limited to the implementation of a single initiative, whilst others met with Facilitators in variety of

contexts and had ongoing relationships with them. Also the length of the relationship with the

Facilitator varied greatly, some informants had only recently met and worked with the Facilitator,

often around a single initiative, whilst others had been working with the Facilitators for some time,

with a couple of them in one area having worked with the Facilitators when they had been funded

by NAEDI, prior to CRUK taking over management responsibilities.

26

Knowledge of the aims and objectives of the role varied greatly amongst the informants, with some

having a very limited view of what the role could offer based on the work undertaken with the

Facilitator:

“She/he was there purely about just the bowel screening as part of the LES.” Practice Manager

“Just for more promotional awareness sort of things and then follow up really.” GP

There did seem to be a correlation between the amount of contact with a Facilitator and clarity in

relation to the aims and objectives of the role:

“I think that maybe initially I was a bit unclear as to what kind of things she/he was, was part of

her/his role. So I think as time went on I learnt more about what she could do and then she’s

suggested things where she can go out into primary care and really help the projects along.”

CCG Representative

One CCG representative, two of the Public Health leads and four of the GPs interviewed described

established relationships with the Facilitators and had been working with them since appointment.

Some of these individuals had been involved with the appointments process. A number of

interviewees commented on how the role had developed over time:

“The main objective (initially) was to try and get out and engage practices and then engage GPs,

and work out the sort of communications in how to actually organise that best and who to liaise

with and so on. And then as time went on, it became about looking more so at the quality of the

interaction and what the sort of action plans were that were developed with the practices and

what the practices’ reaction was to having somebody come in and talk to them about cancer

referrals and their profile. And then it led onto other areas, such as GP education and audit.”

GP

“I think the role has changed, when they started the priority was around visits to discuss profiles

and develop action plans, now it’s much more about providing bespoke support to the same

practices, it’s also more strategic in the way they work with us (Public Health) and the CCGs, things

like getting awareness and early diagnosis into work plans and strategies etc.”

Public Health Representative

Informants discussed a range of ways in which they first came into contact with Facilitators, these

included:

Being involved in the appointment process

Being contacted by the Facilitator via email or telephone

Meeting the Facilitator at a meeting where the role and individual were introduced

Meeting the Facilitator at a meeting with a shared objective e.g. Cancer Locality Group

A third party suggesting contacting the Facilitator might be useful

All of the informants except one CCG Representative felt the role to be valuable:

27

“So yeah I think that’s the, being able to support practices and support primary care to increase

earlier diagnosis that has a huge benefit to public health.”


“I think they’ve been absolutely crucial in doing the legwork and that tenacious approach with the

practices.” CCG Representative

“And I think having the facilitator there has helped us actually do it, because I think a lot of the

time she’s/he’s highlighting avenues that, funding streams that can support the piece of work if

it’s linked into network objectives. And then obviously a lot of the liaising with practices is not

something that we really have time to do, but her/his role is perfect for that and she’s/he’s

developed a really good relationship with a lot of our practices, and a really good relationship with

our clinical lead. So I’d say probably without her/him it wouldn’t be at the point that it is now, and

it wouldn’t be in line with the timescales that the network are expecting of us I’d say.”

CCG Representative

“Oh I think the facilitators are a great resource. Like I say I would be very stuck without it”

GP

One CCG Representative had reservations about the role in terms of its value in the area where

he/she worked; he/she felt that this was due to a range of pressures experienced by general practice

and the changing roles in relation to commissioning:

“I don’t think that this role has been particularly effective. Now that’s not necessarily the fault of

the facilitator. In terms of general approaches, the Facilitator has made a fair amount of effort in

contacting all the practices in the borough to get access to the practice to go in to speak about

their cancer awareness programme and what it entails. But practices, she/he has found that

practices are very reluctant to see her/him, and in my experience there are a number of reasons

for that. It’s because probably their everyday workloads in dealing with patients and primary

care. There are other things on their plate as it were, like doing QOF, keeping up with notices from

NHS England, managing local services. A number of them have CCG or commissioning

responsibilities now. So in terms of seeing a cancer Facilitator, this frankly comes fairly low down

the list. . . . . . . . . . I think as a model it’s been superseded, this Facilitator approach I think is not all

that relevant when you’ve got CCG models, clinically led models, GP leads within CCGs etc.”

CCG Representative

However, despite the reservations of this CCG Representative regarding the role the GP lead working

within the same CCG area had a very different perspective on the value of the role:

“And she’s/he’s been fantastic actually trying to access the GPs, because if you can imagine that

we’ve got about 45 different GP practices, I as cancer lead am working a limited number of hours

in the role, I think it’s about 12-16 per month, it would be difficult for me to try and get into each

and every single one of those GP practices. I think the model is complimentary and works well.”

GP

28

The issue of role credibility was explored in some depth with all of the informants. The general

consensus was that the role was viewed as credible by most people. Some interviewees felt that

because it was linked to CRUK that added to the credibility, others felt that it was more valuable

when the Facilitators aligned themselves to the local CCG Cancer Lead or locality GP Lead. Generally,

interviewees felt that because Facilitators had managed to gain access to practices within their areas

that suggested a degree of credibility and role acceptability to general practice:

“But just from the feedback that AAA has received from the practices I think she’s/he’s got quite a

lot of positive qualitative feedback from practices if they’ve written an email. And she’s/he’s had

quite a lot of practice visits, and she’s/he’s had several second visits with practices, or even third

visits, so I think that in itself suggests that it’s an acceptable role. And I think the way that AAA

phrases her/his emails and the support that she/he provides is very flexible, so I think that in itself

makes it more acceptable and more feasible for practices. It’s not a very rigid you must, I’m only

available at this time, and it’s very tailored to the practices. So I imagine that practices, GPs would

find it acceptable.” Public Health Representative

“And as I say I do know they’ve been going into practices and I think GPs definitely do see them as

credible.” Practice Nurse

Many informants felt that being able to access general practice was a measure of credibility itself

because if the Facilitators were not viewed as credible, practices would not waste time seeing them:

“Well , I think all I can say is X’s role has been well received and I think out of 54 practices at last

count I think he’s/she’s seen 44, she’s made a big effort and has ben obviously, because that

speaks for itself really.” GP

“I think the fact we’ve managed to get all practices on board with this across the patch is, you

know I think it shows that practices do feel that CRUK are credible and I think that’s , you know,

just by that fact it speaks volumes really.” CCG Representative

A number of informants mentioned the background of the Facilitators; some felt it was useful if

people had background knowledge of the organisations they were working with:

“I think one had worked at the PCT for quite some time before, so maybe had that, had

relationships with people that maybe others haven’t, and that always helps if you’ve got some sort

of corporate history, I suppose, then it’s easier to gain credibility.”


“Knowing some of the people prior to taking up post I think has been advantageous, I think it

opens doors more quickly because people will see you because they know you, sometimes with

new roles and unknown people it’s harder to access busy people in CCGs and General Practice.”

CCG Representative

29

There was plenty of discussion relating to whether having a clinical background would enhance the

role with three positions being articulated; firstly that it made no difference what so ever, so long as

the Facilitator was knowledgeable in terms of the topic area, secondly, that it would be more

effective if the post holders had a clinical background and thirdly, there is value in the post holder

being non clinical:

“It really doesn’t matter whether the post holder is clinical or not, so long as they have a good

knowledge base and know how to communicate with and support the people they are working

with, the background doesn’t matter.” GP

“My feeling is it would be a stronger role if it was a clinical role. No detriment or disrespect to the

people we’ve got in post at all, but I think it’s just the whole thing about doctors will respect

another doctor more than a non-doctor.” CCG Representative

“I think there is some value in the fact that she’s/he’s non clinical as well, because I think that it’s

almost, I think that some people thought maybe that would be an issue with it not having a clinical

background, but actually I think in some ways it helps because it’s not. I suppose it’s different

from peer to peer work, it’s more somebody there as a support, and I think that’s been quite yeah.

I don’t think it’s an issue, I don’t think GPs feel like oh well I’m not going to listen to this person

because they’re not clinical. I think that they still seem to be interested in what she’s/he’s saying,

and find the things that they’re discussing in the meetings very useful.”


Interestingly, none of the GPs interviewed felt the Facilitator role should have a clinical background;

they did however see the need for the role to be effectively supported by the locality GP Leads and

the CCG and Public Health Cancer Leads. This support requirement is summed up below:

“I’d say that they need the backup of a GP or a clinician to reinforce that really. I think if they go

out without that GP support there is less credibility than if they have it, and they seem to have it.”

CCG Representative

“Support from the CCG also makes a difference, if they support and are seen to endorse the wok of

the Facilitators, that helps them in terms of gaining access to practices because they know the CCG

are behind the initiative, so that lends credibility too.” GP

It is clear that views vary greatly in terms of the desired background of the Facilitators in order for

them to be viewed as credible, however everyone interviewed agreed that credibility is earned and

only comes about through hard work:

I suppose I was saying that that credibility is not just something you automatically get, you’ve got

to establish it, and that comes with time and working with people and the quality of work that you

deliver.” Public Health Representative

4.2 Deviation from the role

Informants identified 2 areas of activity which were not specifically identified within the job

description, these included working directly with patients and working with wider primary care

professionals such as community pharmacies:

30

“So she’s/he’s worked on a campaign in pharmacies for us, so it’s not strictly what her/his role was

originally for, but we feel that that’s a really important avenue as well, the other side of it, that if

the pharmacists are to try and get people into primary care, and helping with some of those

projects as well.” Public Health Representative

“So they have been involved with pop up clinics, promoting direct to the public, and that’s been

really useful.” Public Health Representative

No evidence was provided during the interviews of outcomes in relation to these activities and it is

difficult to assess whether this was a valid use of Facilitator time. Certainly working with community

pharmacies could be classed as a wider primary care initiative, as alluded to within the job

description.

4.3 Challenges/barriers to effective working

When asked about challenges/barriers to effective working experienced by the Facilitators one GP

talked about initial misconceptions relating to the role and concerns about there being a

performance management function:

“I think there was a slight nervousness and apprehension at the beginning, because a lot of people

are being performance managed, especially when profiles are brought out, but I think actually

most of the time, from what I can see, the profiles just stimulated healthy discussion and the

chance for practices to look at their practice from another perspective. “ GP

Other informants felt that some of the NHS organisational changes implemented in 2013 had had a

significant impact on the way the Facilitators worked, making it more difficult to identify champions

in partner organisations and navigate different organisational structures. Examples cited included

the move of Public Health into Local Authorities and as a result some of their priorities have

changed, also capacity has reduced which may impact on the support available to the Facilitators.

The demise of Cancer Networks with whom the original Facilitators had close links was also cited as

another factor which may have impacted on the Facilitators’ ability to carry out their role:

“We commissioned her role back when public health were in the NHS. Now we’ve moved into the

local authority so I think we have less of a focus on primary care than we did when we were in the

NHS.” Public Health Representative

“Now the (cancer) networks have gone I think it’s harder to join things up, I’m not really sure

where the oversight comes from anymore. We’ve lost some good staff who were very supportive

of the Facilitator role and we’ve lost a lot of organisational memory which I think would have

helped them (the Facilitators).” GP

“I think it is difficult at the moment. Practices always say they’re busy but it seems to be

particularly so and increasing, and I think kind of their appetite for taking on new pieces of work

has diminished since the CCGs came along.” CCG Representative

No explanation was given as to why practices might be less engaged since the emergence of the

CCGs though it may be due to there being more performance measures in place, taking time away

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from new developments, and/or greater GP involvement in commissioning services diverting time

and attention from other initiatives.

In the 2012/13 evaluation time and capacity were identified as significant barriers to the

implementation of change, since practices are under pressure to modernise services across a range

of competing priorities. It was even difficult for some practices to find time to meet with Facilitators

due to existing workload pressures. This appears to remain an important issue and can affect the

Facilitators ability to gain access to General Practice:

“I think the main barriers are GP time. I think getting them on-board; I think that’s probably one

of the main barriers. I think a lot would quite like to have the support but don’t really have the

time to make time for AAA to come in for a visit, or don’t even have time to read their emails, so

might not be aware of the project. So I think that’s probably the main barrier really, yeah.”


“Yes, it’s difficult, I mean I don’t know how she/he or someone in her/his role has the opportunity

to go and see GPs because they’re busy.” GP

In 2012/13 we also identified time as a pressure for facilitators, some of whom have a large number

of practices to which they need to provide support, in addition to a range of meetings and

individuals with whom they need to maintain regular contact. This can be problematic as many of

the informants felt it was the tenacity of the Facilitators, repeat visits and repetition of messages

which acted as a catalyst for change. As per previous evaluations the issue of gaining access to some

“hard to reach” practices remains:

“I think we just have issues with engaging some of our practices, and I think that will be regardless

of who was trying to do it or who they were.” CCG Representative

Interestingly one CCG Representative talked about two different localities for which he/she was

responsible and how one locality readily accepted the Facilitator and had provided some really good

examples of how they had changed things for the better. The other locality was much more of a

challenge; the Facilitator found it difficult to gain access to practices and was really struggling to

have meaningful dialogue with them. When asked whether he/ she had any idea why this might be

the case he/she speculated that it was due to practice size:

“I think it’s the nature of the practices generally. They tend, I would say there’s a lot more

singlehanded practices in the south of our patch, and then I usually get told that that’s not actually

correct anymore, but generally they seem to work more independently and be smaller practices.”

CCG Representative

A number of informants commented on the need to regularly remind people that the Facilitators

exist as a resource to them; it is perceived that people forget they exist or at the very least forget the

range of help and support they can offer:

“I suppose it’s probably sometimes remembering that they’re there. You know, so you tend to go

off and you develop stuff, and actually it’s remembering that they’re there as a resource. And

maybe that’s because I’m almost like I’m in public health and I’m part of the local authority, you

32

sort of perceive the facilitator role as being very much NHS-centric and the links to primary care.

So I suppose it’s bearing them in mind when you are planning and developing stuff.”


“I think there’s a definite need to re-launch the role locally; practices forget the Facilitators are

there, unless they’ve worked with them a lot. Sometimes it’s out of sight out of mind, and sending

emails isn’t enough, many of my colleagues don’t even read them. And let’s face it it’s very unlike

general practice not to utilise something that comes as a free resource and do some of the work

for you.” GP

4.4 Key Facilitator behaviours

The CRUK Facilitator job description identifies the following behaviours as key to the role:

Expertise including communication, facilitation and influencing skills, the ability to develop tailored

solutions/action plans and lead on their implementation. For the purpose of this evaluation

education and training have also been discussed in relation to this theme.

Leadership and Impact, including the ability to prioritise and manage multiple projects. The ability to

be flexible and adapt to different settings was also essential. For the purposes of this evaluation

change management will also be discussed under this heading.

Resource management, requiring organisational and project management skills, the ability to

understand, interpret and present complex data in a clear manner.

4.4.1 Expertise

Communication skills were identified as a key component of the CRUK Facilitator role and

throughout the interviews informants provided examples of the sort of issues communicated by

Facilitators and the methods they used. Examples included emails, providing updates at meetings,

attendance at 1:1 and team meetings and providing training and information at educational events.

At an operational level, Facilitators provided information about practice profiles, promoted Risk

Assessment Tools (RATs), gave information about audit, details about screening programmes or local

initiatives, dealing with local specific practice or CCG level queries and sharing good practice:

“They have communicated all sorts of really useful information to practices, not just things like

practice profile information but they’ve told people about RATs and audit and stuff like that. If a

practice has an issue with something that they’ve come across before, they can share how

someone else has resolved it and something like that is always helpful to know.”

GP

“And actually that’s one thing that is another really valuable aspect of having a Facilitator;

she’s/he’s really good at updating me on other things that are happening. So in area B things

might be happening or things that are happening in CRUK that I might not have heard about, so

she’s/he’s very good communicating most sources of information.”


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“So if they hear of a good piece of work that’s going on in one of our neighbouring CCGs, they’re

able to tell us about it, share documentation if the CCG agrees and so on, that sort of information

is really useful.” CCG Representative

At a more strategic level some of the more established Facilitators have been working with Public

Health and CCG colleagues to ensure that awareness and early diagnosis remains a high priority and

is included in Joint Strategic Needs Assessments (JSNA) and CCG strategies and work plans:

“More recently we have been working (with the Facilitator) to ensure that awareness and early

diagnosis is included as a priority area in our strategic plans, I don’t think we would have been as

effective in doing that without the support of the Facilitator. We’ve also adopted some of the

Facilitators objectives in our strategic plans.”

CCG Representative

“We’ve got awareness and early diagnosis included in our JSNA and we’ve done that with the help

of our CRUK Facilitator.” Public Health Representative

All informants felt communications received from the Facilitators were appropriate and timely and

generally delivered via the most appropriate mechanism, however there was a note of caution

expressed by 3 interviewees in relation to the use of emails, in that not all GPs read their emails and

the risk of over using emails. One CCG representative felt it was particularly important to manage

the flow of information going to GPs and to utilise the CCG Lead to support that:

“So I suppose from that point of view it’s trying to find the balance and not bombard our GP

practices, especially when we’re asking them to do specific projects. So I that’s probably something

I just try and manage a bit, but I mean apart from that, that’s probably the only negative of it

(provision of information from a Facilitator), it’s just the sheer volume of information, but it’s a

small price to pay. CCG Representative

The value of the Facilitators being a conduit for information in both directions was also noted by a

couple of informants:

“And they’ve certainly been very accommodating if there’s any messages we’d like to get out, for

example we’ve got a Macmillan Cancer Information Centre so they’ve been really good raising

awareness of that. You know, there might be an opportunity to discuss the role of the centre and

make sure GPs are aware of it and what it can offer to their patients. So yes it’s useful to do other

things with them as well.” CCG Representative

“We’ve had a number of local initiatives that have been cancer related, although not always

focusing just on the awareness or early diagnosis bit, and the Facilitator has been really good in

raising awareness of them and where appropriate linking general practice with our staff for

support and information purposes. In actual fact their ability to promote our initiatives in general

practice has been particularly useful because we couldn’t possibly get out to all our practices

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because of capacity issue, particularly since we’ve become part of the council.”


Many informants were interested in CRUK updates particularly those professionals who had been

involved with the Facilitators since appointment:

“I was quite involved with the role initially, and got regular feedback about how the Facilitators

were doing and so on, since all the organisational change I don’t get that feedback but I would still

find it useful. I get updates from the Facilitator about what’s going on etc but that’s it really.”

GP

“Right well it all changed from April 1st, because last year my post was funded by CRUK and then

this year they’re not carrying on that way and Macmillan have taken over the primary care cancer

lead role. But in the year I was really mentoring and supervising the Facilitators role, and trying to

work through (his/her) work plan and agree which areas to target . . . . . . . . .obviously I’m still

working closely with the Facilitator but I’m not in the CRUK loop in the way I was previously, and

at the time I thought that was helpful.” GP

Facilitation and influencing skills have also been identified as key requisites of the Facilitator role.

Informants were all asked for evidence of where such skills had been utilized by the facilitators and

many examples were provided of the provision of information, help and support, this interpretation

of facilitation echoes the definition provided by Bentley in section 1.0 of this report.

Examples relating to the provision of information have been discussed and include the provision of

data, information about specific services or initiatives and sharing good practice. Practical support to

carry out audits and develop action plans following audit were discussed by a number of

interviewees as were support to implement change within practice settings:

“I think one of the good things that they were talking about was that we can actually pick up when

people don’t do their screening, that even just to say to them would you consider doing this, this is

why, that people have more information in order to help patients to perhaps reconsider why they

haven’t done something. And I think that was very helpful because I think it raised awareness.”

Practice Nurse

“So things like when we make a cancer referral for example, then we write those down. We didn’t

previously do this about a year ago, but now we write all the referrals, for two-week wait referrals

in a book. And they are, the person that faxes that referral chases that up within two weeks with

the patient to make sure that they’ve been seen. Because sometimes fax go missing and then a

patient just doesn’t, it just gets lost, so for that reason we do do that for example.” GP

“We’ve also been involved in the research study whereby we’ve been sent a load of the bowel

cancer screening kits and DVDs that when we’re up to 100 patients they’re sending them a

different letter with that DVD, and then we have to look again in a certain number of months after

that to see if they’ve been. So these are for patients that DNA’d returning the kits. Because prior

to that we were writing to all our patients that DNA’d and sent them a letter and just a little

bookmark. So this study is sending patients that DNA a more detailed letter and the kit which

35

includes a DVD to see if that increases the uptake. So we’re involved in that through the

Facilitator.” Practice Manager

“People have volunteered to do their own practice audits, to look at their own referral rates, which

have challenged the data that was in the profile.” GP

Education and training is a key part of the Facilitator role, it is often delivered to small groups or

individuals within general practice settings though some Facilitators have delivered training on their

own or in conjunction with others to larger groups:

“We’ve had, since they’ve been in post we’ve had a couple of venue protected learning times

events for general practice. And yeah the Facilitators have been very much involved in that and

they’ve done presentations and prepared data.” CCG Representative

“She/he came to and ran one of the forums with like a training, talking about, doing training with

practice nurses, and we’ve done that twice because they are trying to develop. They’re using us,

my forum, to develop a training package for practice nurses so they’re trying it out on us and using

us as a learning curve. So we’ve had two sessions on doing that, plus she/he came and talked to

the nurses about her/his role initially.” Practice Nurse

4.4.2 Leadership and impact

This includes the ability to prioritise and manage multiple projects. Examples of this sort of activity

tended to come from CCG Representatives, who often had a more strategic view of the Facilitators

activities:

“It must be quite a challenge really, I mean each practice has different skill sets, needs and wants,

so at any one time they could be managing and supporting loads of different projects at different

stages of development and that can’t be easy but they seem to manage it quite well.”

CCG Representative

“Obviously practices needs differ and so often they will want to address different things in

different ways, some need substantial input whilst for others a one off chat will be enough. In

addition to the work with practices there is also the more strategic work with us (the CCG), the GP

Cancer Leads and sometimes Public Health.” CCG Representative

On the whole people interviewed from general practice did not really know what the Facilitator was

doing with other practices:

“We know our Facilitator quite well, she’s/he’s done quite a bit with us because we are motivated

but I’m not sure what sort of response she/he gets in other practices.” GP

“We get visited periodically and in-between we get emails as appropriate but we don’t need a lot

of input, presumably there is a lot more time being spent with other practices if they need more

36

help but I don’t really know. There is also the issue of whether all the practices will accept help or

not.” GP

The role of the Facilitator is complex. As well as managing a range of different projects within

general practice settings, many also work at a more strategic level with Public Health and CCG

Colleagues. This work can range from planning, organising and delivering area wide projects to

ensuring cancer awareness and early diagnosis remains high on local agendas and is included in

strategic plans:

“We’re also just kind of looking at a new piece of work with the Facilitator around PSA follow-up,

and we’re going to look at, you know, how that would work, moving work out from secondary

care into primary care around GPs, doing follow-up and PSA testing, so we’re getting quite a bit of

support from our Facilitator around that as well.” CCG Representative

“We’ve got awareness and early diagnosis in our strategic plans and we couldn’t have included

that to the level we have without the support of our Facilitator.”


A whole range of activities have been carried out and initiatives implemented with the support of

the Facilitators, many have been discussed in section 4.4.1 of this report. Other activities include

supporting “pop up stalls” promoting awareness of cancer and screening to the general public,

building knowledge and awareness of screening and media campaigns with health care professionals

to supporting audit, research and education and promoting service improvements within general

practice and at the primary/secondary care interface. It is evident that in some instances changes

would not have occurred without the support of a Facilitator, particularly those that have happened

within individual general practices.

The majority of informants, however, felt the changes they discussed would have happened

eventually without the Facilitators support though it may have taken longer or been done in a

different way. This supports the view of Petrova et al (2010) that Facilitators can be defined as “a

catalyst for change”:

“It (audit) would not have happened if the Facilitator hadn’t supported it, we simply don’t have

the capacity alongside everything else we are expected to do.” GP

“I’m not sure whether we would have progressed so quickly without the involvement of a

Facilitator, I think we would have got there in the end but probably not quite as quickly.”

CCG Representative

“I think it’s useful for someone external to the practice to help stimulate discussions about our

data and so on, that has helped us to view things differently and take time with him/her (the

Facilitator) to consider how to improve things. We might have done it at some stage internally but

I don’t know . . . .” GP

Whilst the majority of informants were able to articulate changes which occurred as a result of

working with a Facilitator, others felt that they had been influenced by working with a facilitator but

37

found it hard to articulate the changes that had resulted or felt that working with the Facilitator had

had some influence but was not wholly responsible for the changes in practice:

“Apart from awareness, it’s difficult to say. Changed? I don’t think there’s been a drastic change,

but then again I wouldn’t really know until we sort of audit it. But I don’t think so, we are, not

directly from her/him, we have other meetings with various other people from all parts of the GP

life, and so certain activities in the practice have changed, but I don’t know if it’s just due to the

Facilitator or a little mixture of everything.” GP

“I think practices have been influenced by the Facilitator but it’s hard to say whether working with

him/her has been the only reason for change.” CCG Representative

One CCG Representative made the point that practices may have changed what they do as a result

of working with a Facilitator but in some instances may not be willing to share such changes:

“Yeah I think there are probably certain internal processes that have changed as well that they

might not want to be too overt in sharing, if you know what I mean. If late diagnoses has been

found and, you know, there’s something in the practice’s internal working that you might have

picked up on that sooner then I think they’ve probably changed their internal practices but not

necessarily shared that very openly . . . . . But yes there are tangible action plans and actions and

pieces of work that have come out the practice visits.” CCG Representative

The ability to be flexible and adapt to different settings is another important element of the

Facilitator role. Ample evidence was found to support that all Facilitators were adaptable and

flexible:

“We work quite closely. We feel like we’re good friends with the facilitators. So we would have

them along to our strategy planning meetings. We have them at our locality cancer groups, which

are across the area, with a variety of commissioning and providing stakeholders, who we invite

them along to that.” CCG Representative

“I know they work hard to get into practices, and that’s an art in itself, and I think the nature of

the people that you’ve got working in these roles is they are very tenacious and won’t be fobbed

off. But I think the visits have actually been very positive.” CCG Representative

“I think out of our 17 practices I think she’d/he’d managed to get round I think 14 or 15, and had

managed to agree an action plan with them based on their cancer profile. . . . . . . . . I would say

she/he must have been reasonably flexible to be able to have got that done in the time that the

cancer profiles were updated, and when we got the final yeah, these have all got action plans in

place. So I’d say yeah, I’d say that she/he has a flexible approach.”

CCG Representative

“But I think having a whole time person available who’s got flexibility of their timetable usually

copes with most sort of quirky timetables and difficulties in access. So I think the sort of right

38

persistence will enable the facilitator to meet the practices. I think there hasn’t been any

resistance.” GP

Persistence and Tenacity are also identified by the informants as being key to the success of the role.

This also supports the findings of the 2012/13 evaluation which showed that one trait common to

successful GP Cancer Leads and facilitators alike is tenacity (Ablett-Spence, Howse, Gildea and Rubin,

2013).

4.4.3 Scope of influence

The majority of informants felt that the Facilitators had influenced people they had directly worked

with; they found it more difficult to ascertain whether that influence had spread further within their

team or organisation:

“Yeah, no I think because it tends to be, she/he tends to just meet with myself, because I’m the

main person who works on cancer, I don’t think it’s infiltrated into any of the other teams which

focus on other areas of public health.”


“I think it’s generally, because I’m the cancer lead, it is generally myself and the GP lead, but it’s

not to say that if we were doing projects that involved other members of staff, you know, I’m sure

they’d be able to work with them. It’s just by the nature of my role I suppose. “

CCG Representative

“I think they’ve influenced how I do and think about things but I’m not sure whether that’s had a

knock on effect to my colleagues or not really.” GP

However 3 of the informants were very clear that the Facilitators had influenced a wider group of

colleagues:

“There is that engagement and there are those relationships now outside of just me directly. So I

think that’s quite strength, if you like, and that’s come over time because they’re seen as part of

the stakeholder group when we’re looking at issues relating to cancer.”


“They’ve certainly been influential in terms of our Cancer Strategy Group, how we’re shaping

things.” CCG Representative

“I mean the minimum it did was raise awareness to practice nurses. I think it did far more than

that . . . . . . . . . . it’s hard to quantify though” Practice Nurse

4.4.4 Influence on wider cancer work

The majority of informants felt that the Facilitators had a wide range of skills that were potentially

transferable to wider cancer work i.e. not just the awareness and early diagnosis parts of the

pathway there was also a perception that some of their more generic skills may even be useful to

other disease areas:

39

“The practice profiles are a good example, they stimulate discussion and encourage you to

scrutinise your own data, the Facilitators have been great in supporting this and it would be really

good if we could look at other disease areas in a similar way.” GP

“The support we’ve had to do audit has been great, we’ve learnt a lot and the extra capacity to

help us has been really invaluable it’s a shame they can’t help us with audits around other key

disease areas too.” GP

4.4.5 Resource management

Organisational and project management skills are key to the Facilitator role and many examples of

the successful application of these skills have been discussed. Informants were asked if any projects

carried out by or in conjunction with a Facilitator had been unsuccessful, only one informant

reported that the Facilitator could not manage to engage GPs (discussed in section 4.1).

The ability to understand, interpret and present complex data is also an essential requirement of

the role. Many examples of data management, analysis and presentation were given throughout the

interviews, with a consensus that the Facilitators were skilled in this area and the information useful

and thought provoking:

“But yeah, so I think one of the main roles is around the data collection side of things, data

analysis and pulling it all together for us as a CCG, so that at the end of it we’ve got a finalised

report that we can then take through our internal committees and make some decisions on.”

CCG Representative

“We talked about the prevalence where we are, we’ve got very poor pick up rate. We have a lot

of late presentations. So he/she was sharing that information. She/he was talking about the top

five cancers, how they present, what they are, and it was very interactive, finding out what people

actually believed about cancer, what could cause cancer, some of the myths around causes of

cancer. So she/he talked about different treatment options. Those were the sorts of things.”

Practice Nurse

“We’ve just set up a meeting to look at how we can build on the GP practice profiles that the

Facilitators use and build on them using some broader public health intelligence.”


Audit was another key area where the informants felt they had benefited from the support of a

Facilitator. Support ranged from Facilitators raising awareness of the value of audit to providing

practical advice and support and encouragement to follow up on audit results:

“We did an audit on our newly diagnosed cancers, and we looked at where the, who instigated a

referral, where the diagnosis came from, did it start in primary care or was it picked up via A&E,

that sort of thing. And then it’s reported back to us. And I believe we’re going to do another one

starting in June.” Practice Manager

“Yeah, they’ve been doing quite an extensive cancer audit with all our GP practices around

awareness and early diagnosis. That’s been going out to all the practices, linking in with the

40

practices and getting them to do an audit on 10 of their patients to look at the route that patient

took to diagnosis and kind of gone into a big report that’s being produced at the moment, so really

kind of useful piece of work that we’re going to be looking at and then working with those

practices more based on that information. That’s been kind of ongoing”

CCG Representative

4.4.6 Future of the role

The 2012/13 evaluation suggested that the role was useful and that Facilitators were making a

difference by:

Providing increased capacity

Providing additional support to GP practices

Providing additional support to GP Cancer Leads

Signposting practices to areas of other support

Providing a project management function to facilitate the completion of tasks

Working in partnership with network colleagues

All of these impacts were still valid during the interviews carried out for this evaluation, with the

exception of working in partnership with network colleagues. Since the demise of cancer networks,

Facilitators have still needed to work in partnership with individuals who were previously part of the

cancer network, such as GP Cancer Leads, Public Health Leads and secondary care providers.

However the role has evolved and they now have much greater links with CCG commissioners and

more interaction with a whole range of staff within individual general practices, including Practice

Managers, Practice Nurses and administrative staff.

All except one informant felt the role should be continued:

“I think as a model it’s been superseded, this Facilitator approach I think is not all that relevant

when you’ve got CCG models, clinically led models, GP leads within CCGs etc. In terms of, you

know, it’s not for the effort because we’ve pushed it quite a lot to get the access, but it just hasn’t

materialised even with a push which we’ve had since Christmas. So it’s no, I don’t think it’s any

reflection on the facilitator’s personal effort on this, it’s to do with the way that practices respond,

what they feel that they have time for etc.” CCG Representative

Most of the people interviewed felt the role needed to evolve for the future:

“I think there’s a limited number of times that a practice would want to have a visit from a

facilitator around cancer. They’ve got so many other things that they need to think about as well,

I don’t think it would be feasible to have continued visits ongoing all the time. So I think after,

once practices have had a chance to visit, have a visit with the Facilitator, and if there’s nothing, if

it goes a bit quiet and they’re happy to work on the advice that they’ve had through the first

meeting, then I think there’s a bit more of a chance maybe to look at, get involved in other areas

as well.” Public Health Representative

“As with anything, things need to change if they are to evolve, we’ve probably reached an impasse

in terms of practice visits – There’s only so many times you can go back to a practice so there

probably needs to be a re-evaluation of aims and objectives at the very least.”

41

CCG Representative

“Yeah I think we’ve kind of reached a bit of a plateau really in terms of we’ve sort of done what we

can do. We’ve got to the point where they all know where to get the data if they want the data.

You know, they’ve got action plans, whether they’ve actually actioned them or not is maybe

another question. But it kind of feels almost as though it’s plateaued and it needs something

different to happen rather than just continuing as they are. I don’t know what that something

different is but.” CCG Representative

Some informants felt they were only just seeing the benefit of working with the Facilitators and felt

there was value in continuing with a number of activities:

“I’m not sure how I stumbled across her/him, whether by email and I just replied and said yeah

sure, come and see me. But I’m sure a lot of GPs don’t even look at their emails, so would that

have been done, was it seen important enough to get somebody in for the time that it takes? I’m

not really sure. So an awareness of her/his actual role at maybe more of a, one of the bi-monthly

GP meetings, just to make a little bit more awareness of her role so that GPs are aware of it,

because I’m not really sure of the uptake in other practices so I can’t be certain on that. But I

would imagine not everybody’s, she/he doesn’t get to go to every practice, and that could be

improved I would guess.” GP

“I think another training awareness session for non-clinical staff would be quite good in the next

six months. And well, we’re going to do the next audit, which I think starts in June anyway, not

really sure of anything else to be honest. I suppose we’d need Practice manager

A number of informants felt there was some benefit in really “selling” the type of support provided

by the Facilitators:

“I think just maybe being more, maybe more proactive in outlining to practices examples of how

they can help. Because we gets lots of requests from people saying we’re doing this project, we

want to come and meet your GPs, and as I said we have really limited time. We find it difficult to

meet with our GPs, let alone anyone from outside. So if they could maybe be more proactive

saying if you meet with us we can discuss X Y and Z rather than just a general this is our role. ”

Practice Manager

Others felt the role could change to encompass other things:

“Maybe wider cancer work - I suppose there’s always transferable kind of ways of working in

terms of like the audit and the route for diagnosis, so I guess you could do that with other disease

areas, other long-term conditions. I know that we’re certainly looking at working in that way in

terms of looking at cancer as a long-term condition and then looking at long-term conditions

across, you know, in terms of the care and self-care and things like that, but obviously then you

start diluting. I think that data that we can get from working with the facilitator is really

important to us and you potentially lose that if you started working across other long-term

conditions, but certainly working maybe in, you know, across the Survivorship Agenda and things

like that, self-care, you know, that might be really useful.”

CCG Representative

42

“Well I suppose having some direct contact with patients, maybe like with our patient group; I

think that would be helpful, kind of talking about ways to promote screening, getting some

feedback from them really. Yeah, I think that’s probably the only thing that would be additional.”

GP

Whilst the vast majority of informants felt the role is valuable and want it to be continued there

seems to be little consensus about what the role should look like going into the future, however the

following models seem to be the ones were favoured most:

1. Continue the role as per current job description

2. Consider expanding the role to encompass the whole cancer pathway

3. Consider the use of transferable skills to support primary care with the development of

services for non-cancer related disease.

Continuing the role in its current guise would ensure that where spread has been limited to a smaller

number of practices, the Facilitators would have sufficient capacity to engage with those with whom

they had not yet worked. It also allows time for repeat visits and the opportunity for the Facilitators

to build in mechanisms to ensure sustainability of initiatives recently implemented. The drawback to

maintaining the status quo is that some practices may have already reached saturation point with

visits and the Facilitator may make no further impact by continuing to visit, in such instances this

would be inappropriate and poor use of Facilitator time and skills

Expanding the role to encompass the whole cancer pathway, may have some merit, in that there

may be some additional work to be done in terms of pathways to diagnostics, treatment and

primary care follow up and survivorship. However, any extension to the role would need to be

considered carefully, with existing service provision being mapped so as not to duplicate roles that

already exist to address these issues. Any role expansion needs to be focused on the transferable

skills relating to change management and service development rather than specialist clinical

knowledge.

Some informants felt that the Facilitators’ skills in audit change management linked with their

capacity to provide support, might be useful for other chronic diseases such as COPD. However, this

approach would need careful consideration regarding what skills are transferable, what is the same

or similar to cancer and what is different. The differences may be too significant for a change in role

to be viable. Furthermore the posts are currently funded by CRUK whose focus and funding is for

cancer related activity.

5.0 Discussion

The CRUK Facilitator role is complex. There is considerable flexibility in how the objectives are

delivered, with individual Facilitators being able to decide in conjunction with the people they are

supporting, the priorities for that practice or locality and the most appropriate methods for

achieving them.

As per the 2012/13 evaluation the Facilitators continue to make a difference by:

Providing increased capacity

Providing additional support to GP practices

43

Providing additional support to GP Cancer Leads

Signposting practices to areas of other support

Providing a project management function to facilitate the completion of tasks

In addition, this year’s evaluation suggests that they also make a difference by:

Influencing strategies including JSNAs and Commissioning plans

Working in partnership with GP Cancer Leads, Public Health, CCG Commissioners and

secondary care colleagues

Raising awareness of the importance of early diagnosis across a range of settings

Encouraging practices to scrutinise their data and supporting the development of action

plans to address any identified need

Facilitators appear to continue to be very effective at getting into general practice but there is still

no way of knowing whether this is due to the additional capacity they bring above that of a GP

Cancer Lead or whether it is due to their individual personalities and tenacious approach.

5.1 Key Responsibilities

The interviews provide substantial evidence of the Facilitators achieving the key responsibilities

defined within their job description, though some individuals appear more effective in some areas

than others.

Facilitation of relationships between primary and secondary care does occur but was more evident

in the examples given in the case studies contained in our 2012/13 evaluation. This could be due to

the fact that the Cancer Networks no longer exist and they had previously had a central role in

instigating work aimed at improving the primary/secondary care interface.

There is no doubt that the Facilitators share good practice between themselves and with partners;

however examples provided by informants suggested that this was done informally at a practice

level or via discussions with CCG Commissioners. There could be more scope to share on a wider

scale across a locality for example via education sessions or via newsletters.

5.2 Key Behaviours and Competencies

5.2.1 Expertise

We found that Facilitators worked with a diverse range of stakeholders to influence and develop

change. The aim is for those changes to be sustainable but in the majority of examples provided it

was too early to assess this. Examples of action planning and the Facilitators providing a range of

suggestions about how things might be implemented were also provided. There was also substantial

evidence that the Facilitators communicated effectively in a timely manner and in a range of

formats, however GPs and Public Health colleagues in particular want more information and there is

a need to communicate better to all stakeholders prior to implementing new initiatives. This sort of

44

communication also helps with ownership and allows clinicians and managers to fully consider the

potential ramifications of new initiatives, which may ultimately affect the success of an initiative.

Where education and training had been provided by the Facilitators, this was highly valued. Some

innovative work appears to have been undertaken in one area aimed at administrative and clerical

staff, whilst one other area has done some interesting work with Practice Nurses. There is an

opportunity to share, roll out and possibly look at accreditation for these sorts of programmes.

5.2.2 Leadership and Impact

Informants provided examples of the Facilitators being involved in a range of initiatives, though

many of the informants acknowledged they only had a limited view of the Facilitator role and the

diversity of the projects they were involved in.

Everyone who was interviewed felt that the Facilitators were responsive and very flexible in meeting

the needs of those they were aiming to support.

5.2.3 Resource Management

Examples of successful implementation of projects were provided by the majority of informants

which suggests good organisational and project management skills. One area which was highly

valued by the majority of informants was the Facilitators ability to understand and interpret data.

There was consensus that they were able to present complex data in a clear concise manner and to

support discussions regarding actions to address findings and what options were available. The

facilitators also provided information regarding other resources that might support practices, public

health and commissioners, this information related to additional data sources, information regarding

useful contacts, information regarding service provision and on occasion’s information about

potential funding sources to support initiatives.

5.4 Challenges

The Facilitators have faced a number of challenges to developing and maintaining the impetus

around awareness and early diagnosis within primary care and to the implementation of the

Facilitator role.

The Facilitators came into post at time of significant change. All the organisations involved are still

coming to terms with different people in existing roles, new roles and individuals and organisations

having new responsibilities. Informants indicate that Public Health has less involvement with primary

care than previously and CCGs have different responsibilities to PCTs with many people still coming

to terms with their new roles and responsibilities. The leadership function and associated support

provided by the Cancer Networks to the Facilitators has gone and in some areas no organisation or

individual has picked up this function.

Clinicians are familiar with reviewing evidence to inform their decision making. The Facilitators do

ensure that evidence is disseminated and readily accessible to clinicians but there is still a perception

that more of this sort of information could be collected, stored and disseminated.

Clinical engagement is key to the success of the Facilitator role, the GP Cancer Leads are engaged

and motivated but their work with individual practices varies greatly and some practices have not

45

yet had input from a Facilitator. Where leaders have been identified within individual practices the

GP Leads report better engagement.

As with the 2012/13 evaluation there is an acknowledgement that change takes time, and that there

needs to be a significant amount of repetition to support and achieve sustained change. At the

same time, there appears to be a saturation point beyond which engagement on the current model

will lose its impact. They key to effective change is to ensure ownership by the organisation and

individuals within it and by ‘changing hearts and minds’. Primary care is a complex environment

made up of many professional groups and alliances, but the evidence from this study is of a

successful initiative within that complex setting.

5.6 Strengths and weaknesses

This evaluation builds upon the evaluation report for 2012/13 (Ablett-Spence, Howse, Gildea and

Rubin, 2013), and is intended to provide additional understanding relating to the impact of the CRUK

Facilitator role. It should be considered in conjunction with the previous evaluation. A range of

methods have been employed to evaluate the role, including analysis of data from national

databases and 1:1 interviews with professionals who have worked with the Facilitators.

The weaknesses of this evaluation include the fact that not all professional groups were equally

represented in the interviews and the informants had significant differences in the amount of time

they had worked with the Facilitators and the intensity of the interactions they had had with them.

Potential interviewees were also identified by the facilitators themselves and this obviously

introduces a risk of recruitment bias, which we sought to mitigate by selecting those to be

interviewed from a cross section of potential participants.

5.7 Conclusions

In this pilot, facilitators were introduced in a small number of localities within two cancer networks.

Their impact has been positive at both practice and CCG level, with almost double the number of

practices being involved in one or more of three specified activities. They have had an effect on

referral metrics, notably by reducing variation in practice. Other effects, on conversion and

detection rates, are less clear and may reflect a ‘ceiling’ effect or selection bias, with facilitators

being taken up by CCGs that were already performing comparatively well compared to the rest of

England, and certainly in comparison to equivalent CCGs. The future model for supporting primary

care improvement in cancer diagnosis may need to evolve if practices are to embed such activities

into their organisational culture rather than treat them as time-limited projects.

Our findings indicate that facilitators are most effective as agents of change at practice and CCG

level, rather than simply taking data to practices and explaining it. Given that this initiative was

supported by short-term charitable funding, their continued impact presupposes CCGs buy into the

model.

5.8 Recommendations

Our recommendations are that:

46

1. This model of facilitation was acceptable and effective at both practice and CCG level. The

skill set and approach taken were broadly generic and would readily adapt to other disease

areas. CCGs should consider its adoption as a means of influencing quality improvement.

2. In order for a facilitation model of this type to become embedded, a sustainable funding

stream should be identified. Some progressive transition from the current arrangement to

NHS funding is necessary.

47

6.0 References

Ablett-Spence I, Howse J, Gildea C & Rubin G (2013) The NAEDI/Cancer Networks Supporting Primary

Care Programme 2012 to 2013. Durham University

Ablett-Spence I, Howse J & Rubin G (2012) NCAT/Cancer Networks Supporting Primary Care. Durham

University

Bentley T (1994) Facilitation: Providing opportunities for learning. London: McGraw Hill

Hogg W, Baskerville N, Nykiforuk C & Mallen D (2002) Improve preventative care in family practices

with outreach facilitation, understanding success and failure. Journal of Health Service Research

Policy 2002; 7: 195-2009

O’Brien, M.A.; Rogers, S.; Jamtvedt, G.; Oxman, A.D.; Ogaard-Jenson, J; Kristoffersen, D.T.;

Forsetlund, L.; Bainbridge, D.; Freemantle, N; Davis, D.A.; Haynes, R.B. and Harvey, E.L. (2008)

Educational outreach visits: effects on professional practice and health care outcomes (Review)

Cochrane Database Systematic Review2008 (Reprint) Issue 3

Petrova M, Dale J, Munday D, Agarwal S & Lali R (2010) The role and impact of facilitators in primary

care: findings from the implementation of the Gold Standards Framework for palliative care. Family

Practice 27(1): 38-47

Srivastava A & Thomson S B (2009) Framework Analysis: A Qualitative Methodology for Applied

Policy Research. JOAAG, Vol 4. No 2

48

7.0 Glossary

CCG Clinical Commissioning Group

CRUK Cancer Research UK

GP General Practitioner

JSNA Joint Strategic Needs Assessment

LES Local Enhanced Service

NAEDI National Awareness and Early Diagnosis Initiative

NCAT National Cancer Action Team

NHS National Health Service

PCT Primary Care Trust

RAT Risk Assessment Tool

49

Appendix 1- Ethics Approval

Rebecca Maier Research, Development and Trials Manager Chair, School of Medicine, Pharmacy and Health Ethics Sub-Committee

Professor G Rubin Evaluation, Research and Development Unit School of Medicine, Pharmacy and Health Durham University 12th March 2014 Dear Greg, Re: Ethics Application ESC2/2014/PP01 Evaluation of CRUK Primary Care Facilitator role Thank you for sending the above application to the School of Medicine, Pharmacy and Health Ethics Sub-Committee for proportionate ethical review. I reviewed this project as Chair of the committee. The project is an evaluation and review by the full committee is therefore not required. No significant ethical issues were identified, and I am pleased to confirm Durham University ethical approval for the evaluation. This approval is given on the following basis: • That data generated for this study is maintained and destroyed as outlined in this proposal and in keeping with the Data Protection Act. • If you make any amendments to your study, these must be approved by the committee prior to implementation. • At the end of the study, please submit a short end of study report (ESC3 form) to the School ethics committee.

Please do not hesitate to contact me should you have any questions. Good luck, I hope that the evaluation goes well. With best wishes, Rebecca Maier

Cc: Dr Ablett-Spence

50

Appendix 2 - Statistical methods

To account for differing age-profiles between practices and over time, referral rates are age

standardised. At a GP practice level, the rates were indirectly age-sex-standardised, by dividing the

observed number of referrals by the expected number of referrals based on the crude age-sex-

specific referral rates in England. Results can be compared to the expected England level of 100. At

an area or intervention group level, the rates were directly age-standardised using the 20132

European Standard Population weights, and are presented as rates per 100,000 population.

In addition to the rates, 95% confidence intervals have been calculated. For age-sex standardised

referral ratios, these confidence intervals were calculated using Byar’s approximation around the

observed count, scaled down for the ratio using the expected count3. Confidence intervals for the

age-standardised referral rate were based on the Gamma distribution45. For conversion and

detection rates, binomial confidence intervals were calculated using the Wilson Score method4.

Confidence intervals are also provided for the percentage change in referral rate, derived by noting

that the percentage change is a simple transformation of the rate ratio, for which the confidence

interval can be approximated using the normal distribution and a pooled estimate of the standard

error6. For change in the conversion and detection rates, confidence intervals were calculated using

the normal approximation with a pooled estimate of the standard error7.

For age standardised referral rates, the reported p-values are obtained from a z-test, with a null

hypothesis that the ratio of the urgent GP referral rate for the before period to the same rate for the

after period is equal to 1, representing no change from before to after. For conversion and detection

rates, the reported p-values are obtained from a two-sample proportion test, with a null hypothesis

of no difference in the rates for the before and after periods.

2 Note that the 2013 changes to the European Standard Population (ESP) may result in notable differences to

the calculated directly standardised rates, in comparison to rates provided elsewhere or previously, where these were based on the 1976 ESP. 3 Eayres D. APHO Technical Briefing 3: Commonly used public health statistics and their confidence intervals, March 2008.

Accessed from http://www.apho.org.uk/default.aspx?RID=39306 4 Fay MP, Feuer EJ. Confidence intervals for directly standardized rates: a method based on the gamma distribution. Stat

Med. 1997;16:791-801. 5 Tiwari RC, Clegg LX and Zou Z. Efficient interval estimation for age-adjusted cancer rates; Statistical Methods in Medical

Research. 2006; 15: 547–569 6 Breslow NE and Day NE. Statistical Methods in Cancer Research, Volume II - The Design and Analysis of Cohort Studies.

IARC, 1987 7 Dos Santos Silva I. Cancer Epidemiology: Principles and Methods. IARC, 1999

http://www.apho.org.uk/default.aspx?RID=39306

51

Appendix 3: Additional analyses

1.0 Group level rates

The all-cancer results are presented in the main text

1.1 Lung Cancer - Referral Rate

The CRUK Facilitator CCGs had statistically significantly higher referral rates for suspected lung

cancer than the Comparator CCGs in both the before and after intervention periods (Table 1).

However, the Comparator CCGs had a higher, statistically significantly different increase over the

two time periods (43%), compared to 21% for the CRUK Facilitator CCGs.


after intervention periods, lung cancer



to after intervention periods, lung cancer

There were statistically significant increases in lung cancer referral rates in all four CCG intervention

groups between the before and after time periods. The Comparator CCGs’ RAT group had the

highest increase (51%) but the change was only statistically significantly different to the CRUK

Facilitator CCGs’ no RAT group. The Comparator CCGs’ no RAT group had a significantly lower

referral rate to the other three groups in the after time period (Table 2).

Referral

RateLCL UCL

Referral

RateLCL UCL

CRUK Facilitator CCGs 107.7 102.8 112.7 130.4 125.3 135.8 21.1% 14.0% 28.7% <0.001

Comparator CCGs 74.6 70.3 79.0 106.3 101.4 111.4 42.6% 32.3% 53.6% <0.001

P-valueLung Cancer

Before After

Change LCL UCL

52

Table 2: Comparison of referral rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT

intervention group, from before to after intervention periods, lung cancer


Figure 2: Comparison of referral rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT


1.2 Lung Cancer - Conversion Rate

There were no statistically significant differences in lung cancer conversion rates between the CRUK

Facilitator CCGs or Comparator CCGs in either the before or after intervention periods. The CRUK

Facilitator CCGs had a significant decrease of 5 percentage points over the two time periods but

there is no evidence that this change was significantly different to the Comparator CCGs’ decrease

(Table 3).

Table 3: Comparison of conversion rates for CRUK Facilitator CCGs and Comparator CCGs, from

before to after intervention periods, lung cancer

Referral

RateLCL UCL

Referral

RateLCL UCL

RAT 111.8 94.5 131.3 142.2 124.2 162.0 27.1% 3.2% 56.6% 0.024

No RAT 107.4 102.3 112.7 129.3 123.9 134.9 20.4% 13.0% 28.3% <0.001

RAT 85.1 74.6 96.6 128.7 116.5 141.9 51.2% 28.7% 77.6% <0.001

No RAT 72.2 67.6 77.0 101.0 95.7 106.5 39.9% 28.6% 52.2% <0.001

P-value

CRUK Facilitator

CCGs

Comparator CCGs

Lung Cancer

Before After

Change LCL UCL

Conversion

Rate (%)LCL UCL

Conversion

Rate (%)LCL UCL

CRUK Facilitator CCGs 28.0 26.0 30.0 23.2 21.6 25.0 -4.7 -7.3 -2.1 <0.001

Comparator CCGs 25.4 23.0 28.0 22.4 20.6 24.4 -3.0 -6.1 0.2 0.063

P-valueLung Cancer

Before After

Change LCL UCL

53


before to after intervention periods, lung cancer

It can be seen from Table 4 that there were statistically significant decreases in lung cancer

conversion rates in both the CRUK Facilitator CCGs’ RAT and no RAT groups, with the RAT group

having the largest decrease of 9 percentage points. However, there is no evidence that these

changes were significantly different to each other, or to the decreases seen in either the Comparator

CCGs’ RAT or no RAT groups.

Table 4: Comparison of conversion rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT


Conversion

Rate (%)LCL UCL

Conversion

Rate (%)LCL UCL

RAT 33.3 26.4 41.1 23.9 18.9 29.8 -9.4 -18.6 -0.2 0.042

No RAT 27.5 25.4 29.6 23.2 21.5 25.0 -4.3 -7.0 -1.6 0.002

RAT 28.1 22.9 34.0 24.0 20.1 28.3 -4.1 -11.1 2.8 0.237

No RAT 24.7 22.0 27.5 22.0 19.9 24.2 -2.7 -6.2 0.8 0.129

P-value

CRUK Facilitator

CCGs

Comparator CCGs

Lung Cancer

Before After

Change LCL UCL

54

Figure 4: Comparison of conversion rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT


1.3 Lung Cancer - Detection Rate

Table 5 shows that there was a statistically significant increase in the lung cancer detection rate

between the before and after intervention periods in the Comparator CCGs (11 percentage points).

This change was also significantly larger than the CRUK Facilitator CCGs increase.

Table 5: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, from before


Detection

Rate (%)LCL UCL

Detection

Rate (%)LCL UCL

CRUK Facilitator CCGs 43.3 40.5 46.0 44.8 42.1 47.6 1.6 -2.3 5.5 0.430

Comparator CCGs 28.9 26.2 31.7 39.4 36.4 42.4 10.5 6.5 14.6 <0.001

Lung Cancer

Before After


55

Figure 5: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, from before


The Comparator CCGs’ RAT group had the highest, statistically significant increase in the lung cancer

detection rate between the before and after intervention periods (13 percentage points). However,

there is no evidence that this change was significantly different to the changes for any of the three

other intervention group increases (Table 6).

Table 6: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT


Figure 6: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT


Detection

Rate (%)LCL UCL

Detection

Rate (%)LCL UCL

RAT 40.9 32.8 49.6 50.0 40.9 59.1 9.1 -3.5 21.7 0.160

No RAT 43.5 40.6 46.5 44.3 41.5 47.2 0.8 -3.3 4.9 0.701

RAT 31.4 25.7 37.8 44.6 38.3 51.2 13.3 4.3 22.2 0.004

No RAT 28.2 25.2 31.4 37.9 34.6 41.3 9.7 5.2 14.3 <0.001

CRUK Facilitator

CCGs

Comparator CCGs

Lung Cancer

Before After


56

1.4 Colorectal Cancer - Referral Rate

The CRUK Facilitator CCGs had statistically significantly higher referral rates for suspected colorectal

cancer than the Comparator CCGs in both the before (333) and after intervention periods (481),

Table 7. This area also had a larger, statistically significant increase (44%) between the two periods

than the Comparator CCGs (37%), although there is no evidence that the changes were significantly

different between the two areas.


after intervention periods, colorectal cancer



to after intervention periods, colorectal cancer

Between the before and after intervention period, there were statistically significant increases in

colorectal cancer referral rates across all four intervention groups (Table 8). These ranged from a

37% increase in the Comparator CCGs’ no RAT group to an increase of 44% in the CRUK Facilitator

CCGs’ no RAT group. However, there is no evidence of significant differences in the changes,

between the four groups.

Referral

RateLCL UCL

Referral

RateLCL UCL

CRUK Facilitator CCGs 333.4 325.0 342.0 481.2 471.3 491.3 44.3% 39.7% 49.1% <0.001

Comparator CCGs 302.2 293.6 310.9 414.7 405.0 424.6 37.3% 32.3% 42.4% <0.001

P-valueColorectal Cancer

Before After

Change LCL UCL

57

Table 8: Comparison of referral rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT

intervention group, from before to after intervention periods, colorectal cancer


Figure 8: Comparison of referral rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT


1.5 Colorectal Cancer - Conversion Rate

There were small but statistically significant decreases in colorectal cancer conversion rates between

the before and after intervention periods for both the CRUK Facilitator CCGs and Comparator CCGs

(1 and 2 percentage points, respectively). However, there was no evidence of a significant difference

in the changes between the two areas (Table 9).

Table 9: Comparison of conversion rates for CRUK Facilitator CCGs and Comparator CCGs, from

before to after intervention periods, colorectal cancer

Referral

RateLCL UCL

Referral

RateLCL UCL

RAT 353.6 323.7 385.3 507.0 472.9 542.9 43.4% 28.4% 60.1% <0.001

No RAT 331.6 322.8 340.6 478.8 468.4 489.2 44.4% 39.5% 49.4% <0.001

RAT 301.2 281.9 321.5 422.1 399.7 445.5 40.2% 28.8% 52.5% <0.001

No RAT 302.3 292.8 312.0 413.0 402.3 424.0 36.6% 31.1% 42.4% <0.001

P-value

CRUK Facilitator

CCGs

Comparator CCGs

Colorectal Cancer

Before After

Change LCL UCL

Conversion

Rate (%)LCL UCL

Conversion

Rate (%)LCL UCL

CRUK Facilitator CCGs 5.6 5.0 6.2 4.7 4.3 5.2 -0.8 -1.5 -0.1 0.025

Comparator CCGs 6.5 5.8 7.2 4.9 4.4 5.5 -1.5 -2.4 -0.7 <0.001

P-valueColorectal Cancer

Before After

Change LCL UCL

58



Colorectal cancer conversion rates for the CRUK Facilitator CCGs’ RAT group were very similar in

both the before and after intervention periods, with no statistically significant change between the

two periods (Table 10). There were statistically significant decreases in the CRUK Facilitator CCGs’ no

RAT group and the Comparator CCGs’ RAT and no RAT groups of between 1 and 2 percentage points.

However, there was no evidence of a significant difference in the changes across all four

intervention groups.

Table 10: Comparison of conversion rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT


Conversion

Rate (%)LCL UCL

Conversion

Rate (%)LCL UCL

RAT 4.0 2.7 6.0 4.6 3.4 6.2 0.6 -1.6 2.7 0.616

No RAT 5.7 5.1 6.3 4.8 4.3 5.2 -0.9 -1.7 -0.2 0.013

RAT 6.3 4.9 8.0 4.4 3.4 5.6 -1.9 -3.8 0.0 0.045

No RAT 6.5 5.8 7.3 5.1 4.5 5.7 -1.4 -2.4 -0.5 0.002

P-value

CRUK Facilitator

CCGs

Comparator CCGs

Colorectal Cancer

Before After

Change LCL UCL

59

Figure 10: Comparison of conversion rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT


1.6 Colorectal Cancer - Detection Rate

Colorectal cancer detection rates were similar in the CRUK Facilitator CCGs (33%) and Comparator

CCGs (35%) in the before intervention period (Table 11). By the after intervention period, there was

a statistically significant increase in the colorectal cancer detection rate for the CRUK Facilitator

CCGs of 6 percentage points. Rates were very similar over the two periods in the Comparator CCGs.

However, there is no evidence that the CRUK Facilitator change was significantly larger than that for

the Comparator CCGs.

Table 11: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, from


Detection

Rate (%)LCL UCL

Detection

Rate (%)LCL UCL

CRUK Facilitator CCGs 33.0 30.2 35.9 39.3 36.5 42.2 6.4 2.3 10.4 0.002

Comparator CCGs 34.7 31.7 37.9 35.0 32.1 38.0 0.3 -4.0 4.5 0.907

Colorectal Cancer

Before After


60

Figure 11: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, from


In the before intervention period, the Comparator CCGs’ RAT group had the highest colorectal

cancer detection rate (36%) and the CRUK Facilitator CCGs’ RAT group the lowest (27%), although

there was no evidence of a statistically significant difference between all four intervention groups

(Table 12). Detection rates were also comparable between the groups in the after intervention

period, the only statistically significant change between the two periods being an increase of 6

percentage points in the CRUK Facilitator CCGs’ no RAT group but there was no evidence that this

change was significantly larger.

Table 12: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT


Detection

Rate (%)LCL UCL

Detection

Rate (%)LCL UCL

RAT 27.2 18.7 37.7 35.1 26.9 44.4 8.0 -5.2 21.1 0.241

No RAT 33.5 30.5 36.5 39.8 36.8 42.9 6.3 2.1 10.6 0.004

RAT 35.5 28.7 43.1 32.8 26.4 39.9 -2.8 -12.7 7.2 0.588

No RAT 34.5 31.2 38.0 35.5 32.3 38.8 0.9 -3.8 5.7 0.701

CRUK Facilitator

CCGs

Comparator CCGs

Colorectal Cancer

Before After


61

Figure 12: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT


2.0 Practice level changes

2.1 All Cancers - Referral Ratio

A standardised referral ratio (SRR) was calculated for each of the GP practices in the CRUK Facilitator

CCGs and Comparator CCGs, with England as the reference geography. Table 13 presents the

percentage of GP practices in the CRUK Facilitator CCGs and Comparator CCGs with an SRR that was

statistically significantly lower (SL), lower (L), higher (H) or statistically significantly higher (SH), than

nationally, for both the before and after intervention periods.

In the before intervention period, 31% of GP practices in the CRUK Facilitator CCGs had an SRR

statistically significantly lower than the national average; the proportion was higher for the

Comparator CCGs (47%). The CRUK Facilitator CCGs had a greater proportion of GP practices (33%)

with a statistically significantly higher than the national average referral ratio.

In the after period, there had been little change, with a decrease of 2 percentage points in the

proportion of practices with SRRs lower than the national average in the CRUK Facilitator CCGs and

similar decreases in both areas in the proportions of practices with higher than average rates.

Table 13: Percentage of GP practices by comparison of SRR to England average, CRUK Facilitator

CCGs and Comparator CCGs, for before and after intervention periods, all cancers

SL L H SH SL L H SH

CRUK Facilitator CCGs 31.1% 18.3% 17.7% 32.9% 29.1% 19.1% 20.6% 31.1%

Comparator CCGs 47.3% 17.9% 11.2% 23.6% 47.3% 17.6% 13.7% 21.4%

All CancersBefore After

62

Figure 13: Standardised referral ratios for GP practices, CRUK Facilitator CCGs and Comparator CCGs,

for before and after intervention periods, all cancers

In the before period, the variation in standardised referral ratios, as measured by the interquartile

range in Table 14, was smaller for the CRUK Facilitator CCGs (61 points) than for the Comparator

CCGs (69 points). From the before period to the after period, there was a reduction in the variation

in both areas of just over 10 points.

Table 14: Interquartile range of standardised referral ratios, CRUK Facilitator CCGs and Comparator

CCGs, for before and after intervention periods, all cancers

Figure14: Range in standardised referral ratios, CRUK Facilitator CCGs and Comparator CCGs, for


In the before intervention period, the group with the highest proportion of GP practices with an SRR

lower than the national average was the Comparator CCGs’ no intervention group (51%), the CRUK

Facilitator CCGs’ any intervention group had the lowest proportion (29%), Table 15. The CRUK

Facilitator CCGs’ no intervention group had the highest proportion of GP practices with an SRR




63

statistically higher than average (35%) and the Comparator CCGs’ no intervention group the lowest

(21%).

In the after period, the greatest changes were a decrease in the proportion of GP practices with an

SRR lower than the national average in the CRUK Facilitator CCGs’ no intervention group of 8

percentage points and a decrease in the proportion of practices with an SRR higher than average in

the CRUK Facilitator CCGs’ any intervention group of 4 percentage points.

Table 15: Percentage of GP practices by comparison of SRR to England average, for CRUK Facilitator

CCGs and Comparator CCGs, by intervention group, from before to after intervention periods, all

cancers

Figure 15: Standardised referral ratios for GP practices, for CRUK Facilitator CCGs and Comparator

CCGs, by intervention group, from before to after intervention periods, all cancers

In the before period, the variation in standardised referral ratios was smallest for the CRUK

Facilitator CCGs’ any intervention group, at 56 points, compared to the other three intervention

groups, at 66-69 points (Table 15). By the after intervention period, there was a reduction in

variation in all areas, although this was largest for the CRUK Facilitator CCGs’ no intervention group

(14 points) and smallest for the Comparator CCGs’ no intervention group (6 points).

2.2 All Cancers - Conversion Rate

A number of practices do not have any referrals for suspected cancer recorded in the given period.

For these practices, it is not possible to calculate a conversion rate, and so, in Table 26, these are

shown in the “No Rate” column.

SL L H SH SL L H SH

Any Intervention 29.2% 20.4% 18.3% 32.1% 30.0% 17.9% 23.8% 28.3%No Intervention 35.5% 13.6% 16.4% 34.5% 27.3% 21.8% 13.6% 37.3%

Any Intervention 40.2% 20.5% 10.7% 28.6% 40.2% 18.8% 14.3% 26.8%No Intervention 51.2% 16.4% 11.4% 20.9% 51.2% 16.9% 13.4% 18.4%

Before AfterAll Cancers

CRUK Facilitator

CCGs

Comparator CCGs

64

Table 16 presents the percentage of GP practices in the CRUK Facilitator CCGs and Comparator CCGs

with an SRR that was statistically significantly lower (SL), lower (L), higher (H) or statistically

significantly higher (SH), than nationally, for both the before and after intervention periods.

In the before intervention period, the proportion of GP practices with a statistically significantly

lower than the national average all cancers conversion rate was higher in the CRUK Facilitator CCGs

(13%) than the Comparator CCGs (6%). The Comparator CCGs had a larger proportion of practices

with a higher than average rate (12%).

There had been little change in the proportions of practices with statistically significantly lower or

higher than average conversion rates in the after period; the largest being an increase of 4

percentage points in the proportion of practices with a lower than average rate in the Comparator

CCGs.

Table 16: Percentage of GP practices by comparison of conversion rate to England average, CRUK

Facilitator CCGs and Comparator CCGs, for before and after intervention periods, all cancers

Figure 16: Conversion rates for GP practices, CRUK Facilitator CCGs and Comparator CCGs, for before

and after intervention periods, all cancers

Table 17 shows that, in the before intervention period, the interquartile range of conversion rates

was similar for the CRUK Facilitator CCGs and Comparator CCGs, at around 7.5 percentage points. By

the after period, there was a reduction in this variation for both areas, although it was slightly larger

for the CRUK Facilitator CCGs (2.1 percentage points).

Table 17: Interquartile range of conversion rates, CRUK Facilitator CCGs and Comparator CCGs, for


SL L H SH No Rate SL L H SH No Rate

CRUK Facilitator CCGs 12.6% 44.0% 33.7% 9.7% 0.0% 12.6% 44.9% 34.6% 7.7% 0.3%

Comparator CCGs 6.4% 47.0% 33.9% 12.5% 0.3% 10.2% 41.5% 38.3% 9.9% 0.0%





65

Figure 17: Range in conversion rates, CRUK Facilitator CCGs and Comparator CCGs, for before and


In the before period, the CRUK Facilitator CCGs’ no intervention group had the highest proportion of

GP practices with a conversion rate for all cancers that was statistically significantly lower than the

national average (17%), the Comparator CCGs’ any intervention group had the lowest (5%). The

Comparator CCGs’ no intervention group had the highest proportion of practices with a higher than

average conversion rate (13%) and the CRUK Facilitator CCGs’ no intervention group the lowest (9%),

Table 18.

In the after period, the CRUK Facilitator CCGs’ no intervention group still had the highest proportion

of practices with a lower than average conversion rate (15%). However, this was only two

percentage points higher than the Comparator CCGs’ any intervention group (13%), due to an

increase of 8 percentage points over the two time periods in that group. The CRUK Facilitator CCGs’

no intervention group still had the lowest proportion of practices with a conversion rate higher than

the national average (4%), having furthermore decreased by 5 percentage points. Proportions across

the other three intervention groups were broadly similar.

Table 18: Percentage of GP practices by comparison of conversion rate to England average, for CRUK

Facilitator CCGs and Comparator CCGs, by intervention group, from before to after intervention

periods, all cancers


Any Intervention 10.4% 43.3% 36.3% 10.0% 0.0% 11.7% 44.2% 34.6% 9.6% 0.0%

No Intervention 17.3% 45.5% 28.2% 9.1% 0.0% 14.5% 46.4% 34.5% 3.6% 0.9%


No Intervention 7.0% 47.3% 32.8% 12.9% 0.0% 8.5% 44.8% 37.3% 9.5% 0.0%


CRUK Facilitator

CCGs

Comparator CCGs

66

Figure18: Conversion rates for GP practices, for CRUK Facilitator CCGs and Comparator CCGs, by


In the before period, the variation in conversion rates, as shown in Table 18, was largest for the

Comparator CCGs’ no intervention group (8.1 percentage points) and smallest for the Comparator

CCGs’ any intervention group (6.8 percentage points). However, by the after period, this situation

had changed notably, with the Comparator CCGs’ any intervention group having the largest

interquartile range following a small increase of 0.4 percentage points, compared to a reduction of

more than 2 percentage points for both of the CRUK Facilitator CCGs’ intervention groups and for

the Comparator CCGs’ no intervention group. In this after intervention period, the smallest

interquartile range was seen for the CRUK Facilitator CCGs’ no intervention group.

2.3 All Cancers - Detection Rate

A number of practices do not have any cancers recorded on the Cancer Waiting Times database in

the given period. For these practices, it is not possible to calculate a detection rate, and so, in Table

19, these are shown in the “No Rate” column.

As can be seen from Table 19, the Comparator CCGs had the highest proportion of GP practices with

a statistically significantly lower than the national average all cancers detection rate in the before

period (11%). The CRUK Facilitator CCGs had the larger proportion of practices with a higher than

average rate (12%).

In the after period, the proportions of practices with a detection rate lower or higher than the

national average were more similar between the two areas. This was due to a decrease of 4

percentage points in the proportion of practices with lower than average rates in the Comparator

CCGs and a decrease of 5 percentage points in the proportion with higher than average rates in the

CRUK Facilitator CCGs.

67

Table 19: Percentage of GP practices by comparison of detection rate to England average, CRUK

Facilitator CCGs and Comparator CCGs, for before and after intervention periods, all cancers

Figure19: Detection rates for GP practices, CRUK Facilitator CCGs and Comparator CCGs, for before

and after intervention periods, all cancers

Table 20 shows that, in the before period, the interquartile range of detection rates was larger for

the CRUK Facilitator CCGs, at 22 percentage points. However, by the after intervention period, with

a decrease of 4 percentage points, the variation was slightly smaller for this area than for the

Comparator CCGs.

Table 20: Interquartile range of detection rates, CRUK Facilitator CCGs and Comparator CCGs, for




Comparator CCGs 10.9% 51.8% 32.9% 4.5% 0.0% 7.3% 49.8% 40.3% 2.6% 0.0%





68

Figure 20: Range in detection rates, CRUK Facilitator CCGs and Comparator CCGs, for before and


In the before period, the Comparator CCGs’ no intervention group had the highest proportion of GP

practices with a statistically significantly lower than the national average detection rate (12%), the

CRUK Facilitator CCGs’ any intervention group had the lowest (3%), Table 23. The CRUK Facilitator

CCGs’ any intervention group also had the highest proportion of practices with a higher than average

rate (13%); the Comparator CCGs’ any intervention group having the lowest (2%).

In the after period, although the Comparator CCGs’ no intervention group still had the highest

proportion of practices with a detection rate lower than average (10%), the Comparator CCGs’ any

intervention group had the lowest (3%), due to a decrease of 6 percentage points between the two

periods. The CRUK Facilitator CCGs’ any intervention group still had the highest proportion of

practices with a higher than average rate but this had decreased by 5 percentage points; the CRUK

Facilitator CCGs’ no intervention group also decreasing by a similar amount.

Table 21: Percentage of GP practices by comparison of detection rate to England average, for CRUK

Facilitator CCGs and Comparator CCGs, by intervention group, from before to after intervention

periods, all cancers



No Intervention 6.4% 39.1% 43.6% 10.9% 0.0% 3.6% 53.6% 36.4% 5.5% 0.9%


No Intervention 11.9% 50.7% 31.3% 6.0% 0.0% 10.0% 49.8% 36.8% 3.5% 0.0%Comparator CCGs


CRUK Facilitator

CCGs

69

Figure 21: Detection rates for GP practices, for CRUK Facilitator CCGs and Comparator CCGs, by


In the before intervention period, the smallest variation in detection rates was seen for the

Comparator CCGs’ any intervention group (16 percentage points, Table 21), with the largest

variation for the Comparator CCGs’ no intervention group. There were small changes, of less than 1

percentage point, in the variation for both these groups by the after period. However, there were

larger changes for CRUK Facilitator CCGs’ two intervention groups, with 4-5 percentage point

reductions in the interquartile range of detection rates. In both the before period and the after

period, the CRUK Facilitator CCGs’ two intervention groups had similar interquartile ranges to each

other.

2.4 Lung Cancer - Referral Ratio

As can be seen from Table 22, the proportion of GP practices with a lung cancer SRR statistically

significantly lower than the national average in the before intervention period was low in both areas,

the Comparator CCGs having the highest proportion (4%). The CRUK Facilitator CCGs had the highest

proportion of practices with an SRR higher than average (12%).

In the after period, there had been small percentage point increases in the proportion of practices

with lower than average rates in both areas, the CRUK Facilitator CCGs having the largest increase (4

percentage points). There had also been little change in the proportions of practices with a

statistically significantly higher than the national average lung cancer SRR.


CCGs and Comparator CCGs, for before and after intervention periods, lung cancer

SL L H SH SL L H SH


Comparator CCGs 3.8% 62.9% 29.1% 4.2% 6.7% 55.3% 30.4% 7.7%

Before AfterLung Cancer

70


for before and after intervention periods, lung cancer

Table 23 shows some notable differences between areas in the interquartiles ranges of standardised

lung cancer referral ratios. In the before period, the variation is larger for CRUK Facilitator CCGs (106

points) than for Comparator CCGs (84 points). However, the changes by the after period mean that

the variation is similar in both areas (around 97 points). This results from a 9 point reduction in

variation for the CRUK Facilitator CCGs and a 13 point increase in variation for the Comparator CCGs.


CCGs, for before and after intervention periods, lung cancer

Figure 23: Range in standardised referral ratios, CRUK Facilitator CCGs and Comparator CCGs, for

before and after intervention periods, lung cancer

In the before intervention period, the Comparator CCGs’ no RAT group had the highest proportion of

GP practices with a statistically significantly lower than the national average lung cancer SRR,

Lung Cancer Before After Change


Comparator CCGs 83.8 96.5 12.7

71

although this was still small (4%). The CRUK Facilitator CCGs’ no RAT group had the highest

proportion with an SRR higher than average (12%), Table 24.

In the after period, the largest change was an increase of 11 percentage points in the proportion of

practices with an SRR lower than average in the CRUK Facilitator CCGs’ RAT group. The Comparator

CCGs’ RAT group had the highest proportion of GP practices with an SRR higher than the national

average (16%), due to an increase over the two periods of 10 percentage points. Although, it is

important to remember that, considering the small number of practices with RAT interventions,

these RAT group changes reflect changes for a small number of practices, particularly for the CRUK

Facilitator CCGs’ RAT group.


CCGs and Comparator CCGs, by RAT intervention group, from before to after intervention periods,

lung cancer


CCGs, by RAT intervention group, from before to after intervention periods, lung cancer

In the before intervention period, the interquartile range in standardised lung cancer referral ratios

was largest for the CRUK Facilitator CCGs’ no RAT group, at 108 points (Table 25). For the remaining

three intervention groups, the interquartile range was similar, at 85-90 points. However, there was a

notable 46 point increase in variation for the CRUK Facilitator CCGs’ RAT group, resulting in this

group demonstrating the largest interquartile range in the after period. In contrast, the CRUK

Facilitator CCGs’ no RAT group was the only group with a reduction in variation, of 12 points,

bringing it into line with the variation on the Comparator CCGs’ two intervention groups.

SL L H SH SL L H SH

RAT 0.0% 50.0% 39.3% 10.7% 10.7% 35.7% 39.3% 14.3%

No RAT 0.6% 40.1% 47.2% 12.1% 4.3% 44.7% 39.1% 11.8%

RAT 3.3% 54.1% 36.1% 6.6% 1.6% 49.2% 32.8% 16.4%

No RAT 4.0% 65.1% 27.4% 3.6% 7.9% 56.7% 29.8% 5.6%

Lung CancerBefore After

CRUK Facilitator

CCGs

Comparator CCGs

72


Comparator CCGs, by RAT intervention group, from before to after intervention periods, lung cancer


RAT intervention group, from before to after intervention periods, lung cancer

2.5 Lung Cancer - Conversion Rate

In the before intervention period, the proportion of GP practices with a lung cancer conversion rate

statistically significantly lower than the national average was very small in both the CRUK Facilitator

CCGs and Comparator CCGs. The CRUK Facilitator CCGs had the highest proportion of practices with

a higher than average rate (7%), Table 26.

In the after period, there had been little change in the proportions of practices with a lower or

higher than average conversion rate in either area.

Table 26

Before After Change

RAT 89.8 136.0 46.2

No RAT 108.1 96.1 -12.0

RAT 85.1 89.6 4.5

No RAT 86.2 96.0 9.8

Lung Cancer


Comparator CCGs



Comparator CCGs 0.3% 47.0% 29.1% 2.6% 21.1% 0.3% 47.3% 34.2% 3.2% 15.0%


73


and after intervention periods, lung cancer

Table 27 shows that, in the before intervention period, the interquartile range of lung cancer

conversion rates was higher for the CRUK Facilitator CCGs (50 percentage points) than for the

Comparator CCGs (40 percentage points). However, by the after period, a larger reduction of 21

percentage points for the CRUK Facilitator CCGs resulted in a similar variation for the two areas.





Table 28 shows that proportions of GP practices with statistically significantly lower than the

national average conversion rates was very small across all four intervention groups, with little

change between the before and after intervention periods.




74

There was some variation between groups and time periods in the proportions of practices with

higher than average rates. In the before period, the CRUK Facilitator CCGs’ RAT group had the

highest proportion of practices with a statistically significantly higher than the national average

conversion rate (11%). However, in the after period, this had decreased to zero. Although, it is

important to remember that, considering the small number of practices in the CRUK Facilitator CCGs’

RAT group, this change reflects changes for a small number of practices. There were small increases

for the other three intervention groups but these were all less than 2 percentage points.


Facilitator CCGs and Comparator CCGs, by RAT intervention group, from before to after intervention

periods, lung cancer

Figure 28: Conversion rates for GP practices, for CRUK Facilitator CCGs and Comparator CCGs, by RAT


In the before period, the variation in lung cancer conversion rates was the same for the CRUK

Facilitator CCGs’ no RAT group and the Comparator CCGs’ RAT group, both 50 percentage points

(Table 29). The variation was similar, but lower at just under 40 percentage points, for the remaining

two intervention groups. However, the reductions in variation were larger for the CRUK Facilitator

CCGs’ groups, resulting in interquartile ranges of a little under 30 percentage points for these

groups, compared to interquartile ranges of more than 30 percentage points for the Comparator

CCGs’ intervention groups.




RAT 0.0% 46.4% 32.1% 10.7% 10.7% 0.0% 46.4% 42.9% 0.0% 10.7%

No RAT 0.6% 48.4% 36.6% 6.2% 8.1% 0.0% 47.5% 39.8% 6.8% 5.9%

RAT 0.0% 47.5% 37.7% 1.6% 13.1% 1.6% 42.6% 44.3% 3.3% 8.2%

No RAT 0.4% 46.8% 27.0% 2.8% 23.0% 0.0% 48.4% 31.7% 3.2% 16.7%

After

Comparator CCGs

CRUK Facilitator

CCGs

Lung CancerBefore

Before After Change

RAT 38.9 25.0 -13.9

No RAT 50.0 29.2 -20.8

RAT 50.0 38.5 -11.5

No RAT 37.5 33.3 -4.2


Lung Cancer

Comparator CCGs

75

Figure 29: Range in conversion rates, for CRUK Facilitator CCGs and Comparator CCGs, by RAT


2.6 Lung Cancer - Detection Rate

The proportions of GP practices with a lung cancer detection rate statistically significantly lower than

the national average was very small in both the CRUK Facilitator CCGs and Comparator CCGs, with

little change between the two time periods (Table 30).

The CRUK Facilitator CCGs had the highest proportion of practices with a higher than average

detection rate in the before period (6%). In the after period, there was no difference between the

two areas, as there had been a decrease of 3 percentage points for the CRUK Facilitator CCGs and a

smaller increase of 2 percentage points for the Comparator CCGs.


Facilitator CCGs and Comparator CCGs, for before and after intervention periods, lung cancer

Figure 30: Detection rates for GP practices, CRUK Facilitator CCGs and Comparator CCGs, for before

and after intervention periods, lung cancer



Comparator CCGs 1.3% 53.7% 28.8% 1.0% 15.3% 0.0% 44.4% 34.8% 2.9% 17.9%


76

The small number of lung cancers for each practice in each period (often between 0 and 4) means

that there can be little variation between practices in the lung cancer detection rates and so the

interquartile ranges, presented in table 43 and 45, should be interpreted with a note of caution.

Table 31 shows that, for the CRUK Facilitator CCGs, there was little change in the variation of lung

cancer detection rates, as measured by the interquartile range. However, for the Comparator CCGs,

the variation appeared to be larger in the before period (50 percentage points) and also increased by

the after period (to 60 percentage points).








77

It can be seen from Table 33, that proportions of GP practices with statistically significantly lower

than the national average conversion rates were very small across all four intervention groups, with

little change between the before and after intervention periods.

The CRUK Facilitator CCGs’ RAT group had the highest proportion of practices with a higher than

average lung cancer detection rate of the four intervention groups in both the before and after

periods; with the difference widening following an increase of 4 percentage points to 11% in the

after period. Although, it is important to remember that, considering the small number of practices

in the CRUK Facilitator CCGs’ RAT group, this change reflects changes for a small number of

practices. There was also a decrease of 4 percentage points in the proportion of practices with a

higher than average detection rate for the CRUK Facilitator CCGs’ no RAT group between the two

intervention periods, and smaller changes in the two Comparator CCGs’ RAT and no RAT groups.



periods, lung cancer

Figure 32: Detection rates for GP practices, for CRUK Facilitator CCGs and Comparator CCGs, by RAT


Table 34 shows that both the CRUK Facilitator CCGs’ and the Comparator CCGs’ RAT groups

appeared to have higher interquartile ranges in lung cancer detection rates in the before period (60

percentage points in both groups). Furthermore, for these RAT groups, there also appeared to be

similar reductions in variation over the period, decreasing to around 45 percentage points. This

reduction in variation for the RAT groups resulted in interquartile ranges more similar to those for

the two no RAT groups.

Table 34: Interquartile range of detection rates, for CRUK Facilitator CCGs and Comparator CCGs, by



RAT 0.0% 53.6% 32.1% 7.1% 7.1% 0.0% 39.3% 35.7% 10.7% 14.3%

No RAT 0.3% 38.8% 40.7% 5.9% 14.3% 0.0% 36.3% 52.2% 2.2% 9.3%

RAT 0.0% 50.8% 32.8% 3.3% 13.1% 0.0% 34.4% 50.8% 1.6% 13.1%

No RAT 1.6% 54.4% 27.8% 0.4% 15.9% 0.0% 46.8% 31.0% 3.2% 19.0%

AfterLung Cancer

Before

CRUK Facilitator

CCGs

Comparator CCGs

78

Figure 33: Range in detection rates, for CRUK Facilitator CCGs and Comparator CCGs, by RAT


2.7 Colorectal Cancer - Referral Ratio

The Comparator CCGs had a higher proportion of GP practices with a lower than the national

average colorectal cancer SRR in the before intervention period (27%) than the CRUK Facilitator

CCGs (14%). The proportions of practices with a higher than average rate was similar in both areas:

CRUK Facilitator CCGs 17%, Comparator CCGs 14% (Table 35).

In the after period, there had been little change in the proportion of practices with an SRR lower

than the national average in either of the two areas. However, there was a 10 percentage point

difference in the proportions of practices with a higher than average rate between the areas, as the

CRUK Facilitator CCGs rate increased by 5 percentage points to 21% and the Comparator CCGs rate

decreased to 11%.


CCGs and Comparator CCGs, for before and after intervention periods


for before and after intervention periods, colorectal cancer

Before After Change

RAT 60.0 43.3 -16.7

No RAT 40.9 44.2 3.3

RAT 60.0 46.7 -13.3

No RAT 47.2 52.3 5.1

Lung Cancer


Comparator CCGs

SL L H SH SL L H SH


Comparator CCGs 26.5% 36.1% 23.6% 13.7% 27.2% 36.7% 25.6% 10.5%

Colorectal CancerBefore After

79

Table 36 shows that, in the before period, the interquartile range in standardised colorectal cancer

referral ratios is smaller for the CRUK Facilitator CCGs (71 points), compared to the Comparator

CCGs (85 points). However, by the after intervention period, a 16 point reduction in variation for the

Comparator CCGs and little change for the CRUK Facilitator CCGs resulted in a marginally smaller

interquartile range for the Comparator CCGs.


CCGs, for before and after intervention periods, colorectal cancer

Figure 35: Range in standardised referral ratios, CRUK Facilitator CCGs and Comparator CCGs, for

before and after intervention periods, colorectal cancer

As can be seen from Table 37, the Comparator CCGs’ RAT group had the highest proportion of GP

practices with a statistically significantly lower than the national average colorectal cancer SRR in the

before period (33%), the CRUK Facilitator CCGs’ no RAT group had the lowest proportion (14%).

There was little change in the proportions of practices with a lower than average rate in all four

intervention groups between the before and after intervention periods.

Colorectal Cancer Before After Change



80

There was much more variation between the groups and over the two time periods in the

proportions of practices with a higher than average colorectal cancer SRR. In the before period,

proportions were broadly similar, varying between 13% in the Comparator CCGs’ no RAT group to

18% in the CRUK Facilitator CCGs’ RAT group. However, in the after period, there had been an

increase of 18 percentage points in the proportion of practices with an SRR higher than average in

the CRUK Facilitator CCGs’ RAT group. Although, it is important to remember that, considering the

small number of practices in the CRUK Facilitator CCGs’ RAT group, this change reflects changes for a

small number of practices. Despite this, it is still notable that this proportion was 16 percentage

points higher than for the CRUK Facilitator CCGs’ no RAT group and 26 percentage points higher than

for the Comparator CCGs’ RAT group.


CCGs and Comparator CCGs, by RAT intervention group, from before to after intervention periods,

colorectal cancer


CCGs, by RAT intervention group, from before to after intervention periods, colorectal cancer

In the before intervention period, the interquartile range in standardised colorectal cancer referral

ratios is smallest for the CRUK Facilitator CCGs’ no RAT group (69 points) and largest for the

Comparator CCGs’ RAT group (94 points), Table 38. An increase in variation, by the after period, for

the CRUK Facilitator CCGs’ RAT group, results in this group demonstrating the largest interquartile

range. In contrast, reductions in variation for both the Comparator CCGs’ intervention groups,

means the remaining three intervention groups have similar interquartile ranges of around 70

points.

SL L H SH SL L H SH

RAT 14.3% 42.9% 25.0% 17.9% 14.3% 35.7% 14.3% 35.7%

No RAT 14.0% 40.7% 28.9% 16.5% 16.1% 35.1% 28.9% 19.9%

RAT 32.8% 29.5% 21.3% 16.4% 31.1% 29.5% 29.5% 9.8%

No RAT 25.0% 37.7% 24.2% 13.1% 26.2% 38.5% 24.6% 10.7%


CRUK Facilitator

CCGs

Comparator CCGs

81


Comparator CCGs, by RAT intervention group, from before to after intervention periods, colorectal

cancer


RAT intervention group, from before to after intervention periods, colorectal cancer

2.8 Colorectal Conversion Rate

There were no GP practices in either the CRUK Facilitator CCGs or Comparator CCGs with a

conversion rate statistically significantly lower than the national average in the before period, with

very little change in the after period (Table 39).

In the before period, the CRUK Facilitator CCGs had a higher proportion of practices with a higher

than the national average conversion rate (7%). However, the difference between the two areas was

only 2 percentage points. Again, there was with little change between the two periods.

Table 39: Percentage of GP practices by comparison of conversion rate to England average, CRUK

Facilitator CCGs and Comparator CCGs, for before and after intervention periods, colorectal cancer

Before After Change

RAT 85.1 107.0 21.9

No RAT 68.8 69.3 0.5

RAT 94.1 73.2 -20.8

No RAT 82.3 67.7 -14.6

Colorectal Cancer


Comparator CCGs



Comparator CCGs 0.0% 60.7% 27.8% 4.8% 6.7% 0.0% 61.0% 29.1% 6.1% 3.8%


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and after intervention periods, colorectal cancer

Table 40 shows that the interquartile ranges in colorectal cancer conversion rates are similar for the

CRUK Facilitator CCGs and Comparator CCGs, in both the before and after periods.





All four intervention groups had negligible proportions of GP practices with conversion rates

statistically significantly lower than the national average in both the before and after time periods

(Table 41). They also had similar proportions of practices with a higher than average conversion rate

in the before and after period, with little change between the two. The largest change was a

decrease of 2 percentage points in the CRUK Facilitator CCGs’ no RAT group from 7% in the before

period to 5% in the after period.




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periods, colorectal cancer

Figure 40: Conversion rates for GP practices, for CRUK Facilitator CCGs and Comparator CCGs, by RAT


In the before period, the interquartile range of colorectal cancer conversion rates is smallest for the

CRUK Facilitator CCGs’ RAT group (5 percentage points, Table 42). For the remaining three groups,

the variation is more similar at around 9 percentage points. However, an increase in variation for

the CRUK Facilitator CCGs’ RAT group and a reduction in variation for the remaining three

intervention groups mean that, by the after period, all intervention groups demonstrate similar

variation, with an interquartile range of around 7 percentage points.




RAT 0.0% 78.6% 17.9% 3.6% 0.0% 0.0% 57.1% 35.7% 3.6% 3.6%

No RAT 0.0% 63.7% 26.4% 7.5% 2.5% 0.3% 58.4% 34.2% 5.3% 1.9%

RAT 0.0% 59.0% 27.9% 4.9% 8.2% 0.0% 63.9% 29.5% 4.9% 1.6%

No RAT 0.0% 61.1% 27.8% 4.8% 6.3% 0.0% 60.3% 29.0% 6.3% 4.4%


CRUK Facilitator

CCGs

Comparator CCGs

Before After Change

RAT 4.8 6.9 2.1

No RAT 9.1 7.5 -1.5

RAT 8.3 7.1 -1.2

No RAT 8.6 6.7 -2.0

Colorectal Cancer


Comparator CCGs

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Figure 41: Range in conversion rates, for CRUK Facilitator CCGs and Comparator CCGs, by RAT


2.9 Colorectal Cancer - Detection Rate

There were no GP practices in either the CRUK Facilitator CCGs and Comparator CCGs with detection

rates statistically significantly lower than the national average in both the before and after time

periods (Table 43).

Both areas also had very similar proportions of practices with a higher than average detection rate in

the before period (5%). There was also little change over the two periods, the largest being a

decrease of 3 percentage points in the Comparator CCGs.


Facilitator CCGs and Comparator CCGs, for before and after intervention periods



Comparator CCGs 0.0% 42.2% 33.2% 4.8% 19.8% 0.0% 47.0% 33.5% 1.6% 17.9%


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Figure 42: Detection rates for GP practices, CRUK Facilitator CCGs and Comparator CCGs, for before

and after intervention periods, colorectal cancer

The small number of colorectal cancers for each practice in each period (often between 0 and 4)

means that there can be little variation between practices in the colorectal cancer detection rates

and so the interquartile ranges, presented in table 44 cannot be very informative.





There were no GP practices in any of the four intervention groups with colorectal cancer detection

rates statistically significantly lower than the national average in the before and after time periods

(Table 45).




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In the before intervention period the proportions of practices with a higher than average conversion

rate were similar across all four intervention groups. In the after period, the CRUK Facilitator CCGs’

RAT had the highest proportion (7%), having increased by 3 percentage points, with the Comparator

CCGs’ RAT group having decreased to zero. Although, it is important to remember that, considering

the small number of practices with RAT interventions, these RAT group changes reflect changes for a

small number of practices, particularly for the CRUK Facilitator CCGs’ RAT group.



periods, colorectal cancer

Figure 43: Detection rates for GP practices, for CRUK Facilitator CCGs and Comparator CCGs, by RAT


Table 46: Interquartile range of detection rates, for CRUK Facilitator CCGs and Comparator CCGs, by



RAT 0.0% 46.4% 32.1% 3.6% 17.9% 0.0% 64.3% 28.6% 7.1% 0.0%

No RAT 0.0% 45.7% 35.7% 4.7% 14.0% 0.0% 39.1% 40.7% 3.1% 17.1%

RAT 0.0% 37.7% 36.1% 4.9% 21.3% 0.0% 47.5% 37.7% 0.0% 14.8%

No RAT 0.0% 43.3% 32.5% 4.8% 19.4% 0.0% 46.8% 32.5% 2.0% 18.7%Comparator CCGs


CRUK Facilitator

CCGs

Before After Change

RAT 50.0 50.0 0.0

No RAT 50.0 42.9 -7.1

RAT 50.0 50.0 0.0

No RAT 50.0 50.0 0.0Comparator CCGs

Colorectal Cancer


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Figure 44: Range in detection rates, for CRUK Facilitator CCGs and Comparator CCGs, by RAT


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