Living with and beyond cancer
Primary Care
The delivery of personalised care for cancer includes a combination of different interventions, which when delivered together, can greatly improve the outcomes and coordination of care, including better and earlier identification of consequences of treatment.
The key interventions for personalised care are:
- Holistic Needs Assessment and Personalised Care & Support Plan
- End of Treatment Summary
- Personal Stratified Follow Up
- Cancer Care Review
- Prehabilitation
You will find more information below to support your primary care team with undertaking Cancer Care Reviews.
This short video explains how integration between primary, secondary and community plays a key role in delivering personalised care across the entire patient journey.
What is a Cancer Care Review?
With increasing numbers of patients surviving their Cancer diagnosis, primary care has an important role in supporting people to live well with and beyond cancer. The Cancer Care Review (CCR) is a conversation between a patient and their Primary Care team about their cancer journey. It is an opportunity for patients to:
- Talk about their cancer experience and concerns.
- Understand what support is available in their community.
After a cancer diagnosis, people may have lots of appointments and support from their hospital team. However, the Primary Care team is also there to help.
What are the requirements for QOF?
In 2025, key changes were made to the Quality and Outcomes Framework (QOF) cancer requirements. The previous Cancer Care Review targets were both retired.
We recognise the important role that primary care plays to support people after a cancer diagnosis. We recommend that practices continue to offer patients the opportunity for a supportive conversation following a cancer diagnosis, in line with the previous QOF 3-month cancer review target. This can be delivered flexibly—whether through a letter, telephone call, or face-to-face consultation. This ensures continued visibility of primary care to the patient, providing reassurance and making it more likely they will seek help should they need further support.
Involving the wider primary care team
People living with cancer have varied needs and cancer can affect all aspects of their life, from relationships to work or finance. Cancer can have a huge emotional impact on the individual and those around them. Wider members of the Primary Care Team including Cancer Care Co-ordinators and Social prescribers should continue to be utilised to deliver the holistic elements and facilitate discussion.
As individual needs vary, some people may not require a discussion, others may only need limited contact with the Primary Care team. However, for others, more regular contact and review/follow up might be necessary. This should be personalised to the individual needs of the patient.
Supporting patients at diagnosis
Below is a suggested process map (from Cancer Diagnosis) which can be followed by the GP practice.
On receiving a letter or Serious Diagnosis form, it is good practice to make an initial phone call to the patient. GP practices should provide patients with the opportunity for a discussion to make them aware of the support available from the Primary Care team. This is to facilitate early and supportive conversations and ensure patients are aware of what help is available.
This can be done via phone call or you may also choose to send a letter to advise patients about the help that is available. We have created a sample letter including links to support from Macmillan which can be personalised to your GP practice.
👉 Macmillan concerns checklist
What should a Cancer Care Review include?
The Cancer Care Review should be a holistic conversation that covers clinical, practical, emotional, psychological and financial (where appropriate) aspects of the person’s cancer care.
A suggested structure for a Cancer Care Review could include:
- Discussing their diagnosis, treatment and potential consequences (physical, emotional, social, practical).
- Reviewing medication.
- Finding out about the person’s support network and checking if they themselves are a carer.
- Giving the patient the opportunity to raise anything else they wish to discuss.
Macmillan have collated their Primary Care 10 top tips for carrying out an effective Cancer Care Review.
Electronic Cancer Care Review templates
Evidence found that use of a structured template alongside quality improvement activities for holistic cancer care reviews enabled higher quality personalised care conversations to occur. Templates can be used as an aide memoire when carrying out a CCR. It also includes supporting information which can be shared with the patient as well as providing a helpful coded record of topics discussed. Templates are available from Ardens, CRDC and Macmillan.
The Macmillan CCR template is available on all major IT systems and guidance on how to access and integrate them is below.
👉 Macmillan CCR template guidance
Social prescribing in cancer
The aim of social prescribing models is to help people live their lives as well as possible, with a focus on supporting them to take control of and to improve their health, wellbeing and social welfare.
They actively support people to focus on what matters to them and help to build confidence and resilience to enable self-management as appropriate. These roles often support people to navigate care between professionals and to access support for their holistic needs.
For more information on the role that Social Prescribers can play in supporting people living with cancer and how Primary Care Networks can get the best out of these roles, please download the Macmillan resources below.
