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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 j.m.walsh@durham.ac.uk 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: i.m.ablett-spence@durham.ac.uk
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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
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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
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
Note: Referral rate is the directly age-standardised referrals rate per 100,000 person population
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
intervention group, from before to after intervention periods, all cancers
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
intervention group, from before to after intervention periods, all cancers
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
to after intervention periods, all cancers
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
intervention group, from before to after intervention periods, all cancers
Figure 5: Comparison of conversion rates for CRUK Facilitator CCGs and Comparator CCGs, by
intervention group, from before to after intervention periods, all cancers
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
intervention group, from before to after intervention periods, all cancers
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
to after intervention periods, all cancers
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
intervention group, from before to after intervention periods, all cancers
Figure 8: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, by
intervention group, from before to after intervention periods, all cancers
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
Change LCL UCL P-value
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.”
Public Health Representative
“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.”
Public Health Representative
“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.”
Public Health Representative
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.”
Public Health Representative
“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
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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.”
Public Health Representative
“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.”
Public Health Representative
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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.”
Public Health Representative
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.”
Public Health Representative
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.”
Public Health Representative
“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.”
Public Health Representative
“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.”
Public Health Representative
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.”
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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
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.
Table 1: Comparison of referral rates for CRUK Facilitator CCGs and Comparator CCGs, from before to
after intervention periods, lung cancer
Note: Referral rate is the directly age-standardised referrals rate per 100,000 person population
Figure 1: Comparison of referral rates for CRUK Facilitator CCGs and Comparator CCGs, from before
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
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 RAT
intervention group, from before to after intervention periods, lung cancer
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
Figure 3: Comparison of conversion rates for CRUK Facilitator CCGs and Comparator CCGs, from
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
intervention group, from before to after intervention periods, lung cancer
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
intervention group, from before to after intervention periods, lung cancer
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
to after intervention periods, lung cancer
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
Change LCL UCL P-value
55
Figure 5: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, from before
to after intervention periods, lung cancer
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
intervention group, from before to after intervention periods, lung cancer
Figure 6: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT
intervention group, from before to after intervention periods, lung cancer
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
Change LCL UCL P-value
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.
Table 7: Comparison of referral rates for CRUK Facilitator CCGs and Comparator CCGs, from before to
after intervention periods, colorectal cancer
Note: Referral rate is the directly age-standardised referrals rate per 100,000 person population
Figure 7: Comparison of referral rates for CRUK Facilitator CCGs and Comparator CCGs, from before
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
Note: Referral rate is directly age-standardised rate per 100,000 person population
Figure 8: Comparison of referral rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT
intervention group, from before to after intervention periods, colorectal cancer
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
Figure 9: Comparison of conversion rates for CRUK Facilitator CCGs and Comparator CCGs, from
before to after intervention periods, colorectal cancer
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
intervention group, from before to after intervention periods, colorectal cancer
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
intervention group, from before to after intervention periods, colorectal cancer
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
before to after intervention periods, colorectal cancer
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
Change LCL UCL P-value
60
Figure 11: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, from
before to after intervention periods, colorectal cancer
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
intervention group, from before to after intervention periods, colorectal cancer
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
Change LCL UCL P-value
61
Figure 12: Comparison of detection rates for CRUK Facilitator CCGs and Comparator CCGs, by RAT
intervention group, from before to after intervention periods, colorectal cancer
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
before and after intervention periods, all cancers
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
All Cancers Before After Change
CRUK Facilitator CCGs 60.9 49.9 -11.0
Comparator CCGs 68.6 58.0 -10.6
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
before and after intervention periods, all cancers
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%
All CancersBefore After
All Cancers Before After Change
CRUK Facilitator CCGs 7.4 5.3 -2.1
Comparator CCGs 7.6 6.0 -1.6
65
Figure 17: Range in conversion rates, CRUK Facilitator CCGs and Comparator CCGs, for before and
after intervention periods, all cancers
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
SL L H SH No Rate SL L H SH No Rate
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%
Any Intervention 5.4% 46.4% 35.7% 11.6% 0.9% 13.4% 35.7% 40.2% 10.7% 0.0%
No Intervention 7.0% 47.3% 32.8% 12.9% 0.0% 8.5% 44.8% 37.3% 9.5% 0.0%
All CancersBefore After
CRUK Facilitator
CCGs
Comparator CCGs
66
Figure18: Conversion rates 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 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
before and after intervention periods, all cancers
SL L H SH No Rate SL L H SH No Rate
CRUK Facilitator CCGs 4.0% 38.9% 45.1% 12.0% 0.0% 4.0% 50.3% 38.6% 6.6% 0.6%
Comparator CCGs 10.9% 51.8% 32.9% 4.5% 0.0% 7.3% 49.8% 40.3% 2.6% 0.0%
All CancersBefore After
All Cancers Before After Change
CRUK Facilitator CCGs 22.1 17.8 -4.3
Comparator CCGs 20.6 18.2 -2.3
68
Figure 20: Range in detection rates, CRUK Facilitator CCGs and Comparator CCGs, for before and
after intervention periods, all cancers
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
SL L H SH No Rate SL L H SH No Rate
Any Intervention 2.9% 38.8% 45.8% 12.5% 0.0% 4.2% 48.8% 39.6% 7.1% 0.4%
No Intervention 6.4% 39.1% 43.6% 10.9% 0.0% 3.6% 53.6% 36.4% 5.5% 0.9%
Any Intervention 8.9% 53.6% 35.7% 1.8% 0.0% 2.7% 50.0% 46.4% 0.9% 0.0%
No Intervention 11.9% 50.7% 31.3% 6.0% 0.0% 10.0% 49.8% 36.8% 3.5% 0.0%Comparator CCGs
All CancersBefore After
CRUK Facilitator
CCGs
69
Figure 21: Detection rates for GP practices, for CRUK Facilitator CCGs and Comparator CCGs, by
intervention group, from before to after intervention periods, all cancers
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.
Table 22: Percentage of GP practices by comparison of SRR to England average, CRUK Facilitator
CCGs and Comparator CCGs, for before and after intervention periods, lung cancer
SL L H SH SL L H SH
CRUK Facilitator CCGs 0.6% 40.9% 46.6% 12.0% 4.9% 44.0% 39.1% 12.0%
Comparator CCGs 3.8% 62.9% 29.1% 4.2% 6.7% 55.3% 30.4% 7.7%
Before AfterLung Cancer
70
Figure 22: Standardised referral ratios for GP practices, CRUK Facilitator CCGs and Comparator CCGs,
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.
Table 23: Interquartile range of standardised referral ratios, CRUK Facilitator CCGs and Comparator
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
CRUK Facilitator CCGs 106.2 97.2 -9.0
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.
Table 24: Percentage of GP practices by comparison of SRR to England average, for CRUK Facilitator
CCGs and Comparator CCGs, by RAT intervention group, from before to after intervention periods,
lung cancer
Figure 24: Standardised referral ratios for GP practices, for CRUK Facilitator CCGs and Comparator
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
Table 25: Interquartile range of standardised referral ratios, for CRUK Facilitator CCGs and
Comparator CCGs, by RAT intervention group, from before to after intervention periods, lung cancer
Figure 25: Range in standardised referral ratios, for CRUK Facilitator CCGs and Comparator CCGs, by
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
CRUK Facilitator CCGs
Comparator CCGs
SL L H SH No Rate SL L H SH No Rate
CRUK Facilitator CCGs 0.6% 48.3% 36.3% 6.6% 8.3% 0.0% 47.4% 40.0% 6.3% 6.3%
Comparator CCGs 0.3% 47.0% 29.1% 2.6% 21.1% 0.3% 47.3% 34.2% 3.2% 15.0%
Lung CancerBefore After
73
Figure 26: Conversion rates for GP practices, CRUK Facilitator CCGs and Comparator CCGs, for before
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 27: Interquartile range of conversion rates, CRUK Facilitator CCGs and Comparator CCGs, for
before and after intervention periods, lung cancer
Figure 27: Range in conversion rates, CRUK Facilitator CCGs and Comparator CCGs, for before and
after intervention periods, lung cancer
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.
Lung Cancer Before After Change
CRUK Facilitator CCGs 50.0 28.9 -21.1
Comparator CCGs 40.0 33.3 -6.7
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.
Table 28: Percentage of GP practices by comparison of conversion rate to England average, for CRUK
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
intervention group, from before to after intervention periods, lung cancer
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.
Table 29: Interquartile range of conversion rates, for CRUK Facilitator CCGs and Comparator CCGs, by
RAT intervention group, from before to after intervention periods, lung cancer
SL L H SH No Rate SL L H SH No Rate
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
CRUK Facilitator CCGs
Lung Cancer
Comparator CCGs
75
Figure 29: Range in conversion rates, for CRUK Facilitator CCGs and Comparator CCGs, by RAT
intervention group, from before to after intervention periods, lung cancer
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.
Table 30: Percentage of GP practices by comparison of detection rate to England average, CRUK
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
SL L H SH No Rate SL L H SH No Rate
CRUK Facilitator CCGs 0.3% 40.0% 40.0% 6.0% 13.7% 0.0% 36.6% 50.9% 2.9% 9.7%
Comparator CCGs 1.3% 53.7% 28.8% 1.0% 15.3% 0.0% 44.4% 34.8% 2.9% 17.9%
Lung CancerBefore After
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).
Table 32: Interquartile range of detection rates, CRUK Facilitator CCGs and Comparator CCGs, for
before and after intervention periods, lung cancer
Figure 31: Range in detection rates, CRUK Facilitator CCGs and Comparator CCGs, for before and
after intervention periods, lung cancer
Lung Cancer Before After Change
CRUK Facilitator CCGs 41.8 41.7 -0.2
Comparator CCGs 50.0 60.0 10.0
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.
Table 33: Percentage of GP practices by comparison of detection rate to England average, for CRUK
Facilitator CCGs and Comparator CCGs, by RAT intervention group, from before to after intervention
periods, lung cancer
Figure 32: Detection rates for GP practices, for CRUK Facilitator CCGs and Comparator CCGs, by RAT
intervention group, from before to after intervention periods, lung cancer
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 intervention group, from before to after intervention periods, lung cancer
SL L H SH No Rate SL L H SH No Rate
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
intervention group, from before to after intervention periods, lung cancer
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%.
Table 35: Percentage of GP practices by comparison of SRR to England average, CRUK Facilitator
CCGs and Comparator CCGs, for before and after intervention periods
Figure 34: Standardised referral ratios for GP practices, CRUK Facilitator CCGs and Comparator CCGs,
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
CRUK Facilitator CCGs
Comparator CCGs
SL L H SH SL L H SH
CRUK Facilitator CCGs 14.0% 40.9% 28.6% 16.6% 16.0% 35.1% 27.7% 21.1%
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.
Table 36: Interquartile range of standardised referral ratios, CRUK Facilitator CCGs and Comparator
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
CRUK Facilitator CCGs 71.3 71.2 -0.1
Comparator CCGs 85.2 68.9 -16.3
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.
Table 37: Percentage of GP practices by comparison of SRR to England average, for CRUK Facilitator
CCGs and Comparator CCGs, by RAT intervention group, from before to after intervention periods,
colorectal cancer
Figure 36: Standardised referral ratios for GP practices, for CRUK Facilitator CCGs and Comparator
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%
Colorectal CancerBefore After
CRUK Facilitator
CCGs
Comparator CCGs
81
Table 38: Interquartile range of standardised referral ratios, for CRUK Facilitator CCGs and
Comparator CCGs, by RAT intervention group, from before to after intervention periods, colorectal
cancer
Figure 37: Range in standardised referral ratios, for CRUK Facilitator CCGs and Comparator CCGs, by
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
CRUK Facilitator CCGs
Comparator CCGs
SL L H SH No Rate SL L H SH No Rate
CRUK Facilitator CCGs 0.0% 64.9% 25.7% 7.1% 2.3% 0.3% 58.3% 34.3% 5.1% 2.0%
Comparator CCGs 0.0% 60.7% 27.8% 4.8% 6.7% 0.0% 61.0% 29.1% 6.1% 3.8%
Colorectal CancerBefore After
82
Figure 38: Conversion rates for GP practices, CRUK Facilitator CCGs and Comparator CCGs, for before
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.
Table 40: Interquartile range of conversion rates, CRUK Facilitator CCGs and Comparator CCGs, for
before and after intervention periods, colorectal cancer
Figure 39: Range in conversion rates, CRUK Facilitator CCGs and Comparator CCGs, for before and
after intervention periods, colorectal cancer
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.
Colorectal Cancer Before After Change
CRUK Facilitator CCGs 8.9 7.4 -1.5
Comparator CCGs 8.5 6.9 -1.6
83
Table 41: Percentage of GP practices by comparison of conversion rate to England average, for CRUK
Facilitator CCGs and Comparator CCGs, by RAT intervention group, from before to after intervention
periods, colorectal cancer
Figure 40: Conversion rates for GP practices, for CRUK Facilitator CCGs and Comparator CCGs, by RAT
intervention group, from before to after intervention periods, colorectal cancer
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.
Table 42: Interquartile range of conversion rates, for CRUK Facilitator CCGs and Comparator CCGs, by
RAT intervention group, from before to after intervention periods, colorectal cancer
SL L H SH No Rate SL L H SH No Rate
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%
Colorectal CancerBefore After
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
CRUK Facilitator CCGs
Comparator CCGs
84
Figure 41: Range in conversion rates, for CRUK Facilitator CCGs and Comparator CCGs, by RAT
intervention group, from before to after intervention periods, colorectal cancer
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.
Table 43: Percentage of GP practices by comparison of detection rate to England average, CRUK
Facilitator CCGs and Comparator CCGs, for before and after intervention periods
SL L H SH No Rate SL L H SH No Rate
CRUK Facilitator CCGs 0.0% 45.7% 35.4% 4.6% 14.3% 0.0% 41.1% 39.7% 3.4% 15.7%
Comparator CCGs 0.0% 42.2% 33.2% 4.8% 19.8% 0.0% 47.0% 33.5% 1.6% 17.9%
Colorectal CancerBefore After
85
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.
Table 44: Interquartile range of detection rates, CRUK Facilitator CCGs and Comparator CCGs, for
before and after intervention periods, colorectal cancer
Figure 52: Range in detection rates, CRUK Facilitator CCGs and Comparator CCGs, for before and
after intervention periods, colorectal cancer
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).
Colorectal Cancer Before After Change
CRUK Facilitator CCGs 50.0 47.1 -2.9
Comparator CCGs 50.0 50.0 0.0
86
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.
Table 45: Percentage of GP practices by comparison of detection rate to England average, for CRUK
Facilitator CCGs and Comparator CCGs, by RAT intervention group, from before to after intervention
periods, colorectal cancer
Figure 43: Detection rates for GP practices, for CRUK Facilitator CCGs and Comparator CCGs, by RAT
intervention group, from before to after intervention periods, colorectal cancer
Table 46: Interquartile range of detection rates, for CRUK Facilitator CCGs and Comparator CCGs, by
RAT intervention group, from before to after intervention periods, colorectal cancer
SL L H SH No Rate SL L H SH No Rate
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
Colorectal CancerBefore After
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
CRUK Facilitator CCGs
87
Figure 44: Range in detection rates, for CRUK Facilitator CCGs and Comparator CCGs, by RAT
intervention group, from before to after intervention periods, colorectal cancer