Cancer Care Review Pilots

(Oct 2019 - Mar 2020)

Latest evidence suggests that 1 in 2 people will get cancer with the number of people living beyond 5 years from initial diagnosis predicted to more than double between 2010 and 2030 (NCSI, 2013). 

In addition, with an ageing population, people who survive cancer often have other long term conditions.  This has led to a shift in thinking of cancer as an acute illness to a chronic one with the role of primary care in relation to cancer evolving as care inevitably moves out of the acute setting after completion of treatment.

Ultimately patients would like primary care to offer a service that caters for their long term needs and reduce the sense of being alone with their cancer after primary treatment ends.  This is particularly relevant as frequent contact with secondary care reduces. 

The management of unmet needs of patients with cancer during and post-acute treatment has been captured by the National Cancer Survivorship Initiative (NCSI, 2010) which promotes the delivery of Cancer Care Reviews (CCRs) within primary care as part of the Quality Outcomes Framework (QOF) in the form of unspecified reviews to be completed within 6 months of diagnosis.

Dr Peter Holloway, East of England Cancer Alliance Primary Care Group Chair recommends:

“The primary purpose of a Cancer Care Review is to support patients towards self-management by covering their psycho-social and physical needs and incorporating the needs of their carers.  Ideally CCRs should bridge primary and secondary care interface so that the patient has a seamless supported service that is clear and documented.”


(Dr Peter Holloway with a patient at Mendlesham Health Centre)

In order to provide a consistent service to cancer patients within primary care the East of England Cancer Alliance Working Group for Cancer as a Long-Term Condition formed in September 2018 to look at how high quality Cancer Care Reviews (CCRs) can be delivered across the region.

More generally the aim is for cancer to be integrated within a long-term conditions management approach at a GP practice or Sustainability Transformation Partnership (STP) / Integrated Care Systems (ICS) level.


Tonia Dawson, Macmillan Clinical Lead for the East of England Cancer Alliance highlights:

"The overarching aim of the East of England Cancer Alliance Working Group was to lay the groundwork for an infrastructure within primary care to identify, support and empower people across the east of England affected by cancer to reduce social isolation and improve pathways from hospital and build community networks through social support.

The East of England Cancer Alliance has been working closely with Transforming Cancer Services Team (TCST) in London in regards to adopting TSCT’s Holistic 4 Point Model for CCRs. The key element of this model that we are adopting in our pilots across the region is the introduction of a CCR for the patient within 3 months following the end of their active treatment"

 TCST Holistic 4 Point Model for Cancer Care Reviews?

Source: Transforming Cancer Services Team for London (2015)

The aims of the pilots are to improve the current variation of the quality of CCRs across the east of England and inform Primary Care Health Professionals (PCHPs) about how to target areas for improvement to ensure there is equity of access to CCRs for all patients living with and beyond cancer.

The request for accessing Transformation Funding (2019/20) for the CCR pilots across the region was endorsed by the East of England Cancer Alliance Primary Care Group in February 2019 with agreement for the pilots to ‘go live’ from 1st October 2019 – 31st March 2020. 

Anglia Ruskin University (ARU) is being funded to provide an external evaluation of the pilots with a report due in September 2020.  If you would like more information about the East of England CCR Pilots please contact:

Debbie Adger (Senior Programme Manager – Living with & Beyond Cancer)



Please find below documents to support the implementation of the East of England Cancer Care Review Pilots

EoE Cancer Alliance - CCR Business Case a 4 point model for the East of England

EoE Cancer Alliance - CCR 4 Point Model Local Incentive Scheme

EoE Cancer Alliance Template CCR GP Invite Letter

Macmillan Cancer Care Review Template

EoE Cancer Alliance - Primary Care Cancer Checklist

Example EoE Cancer Alliance 1 Day CCR Training Day

QOF CCR Data to support Pilots


Documentation to support CCR Pilot Site WebEx meetings during August 2019

Resource Pack to support Pilots Site to undertake high quality CCRs (vs1.3)

East of England Cancer Alliance CCR Pilot Evaluation Toolkit vs1.8

East of England Cancer Alliance CCR Pilot Data Collection Audit vs1.8 (Windows 97-2003 version)

East of England Cancer Alliance CCR Pilot Data Collection Audit vs1.8

Shaping excellence in cancer care - prevention and access to high quality cancer services across the East of England