The role of primary care in cancer screening

“We have had two (asymptomatic) patients picked up with early breast cancer from our screening [reminders] that otherwise wouldn't have been picked up”
–GP, Port Macquarie17

The role of primary care

While cancer screening registries send reminders, evidence shows that primary care providers play a critical role in cancer screening participation.

  • Formative research conducted by the Cancer Institute NSW found that, 60% of patients surveyed reported they were more likely to screen when reminded by their GP than when reminded by a registry only.2
  • General practice is uniquely positioned, through both patient data and patient relationships, to identify, engage and encourage patient cohorts who are under-screened or who have never screened.
  • Reminders are the only patient intervention rated as ‘very effective’ in the RACGP’s Putting prevention into practice (‘The Green Book’).4
  • Practices participating in Cancer Institute NSW cancer screening quality improvement projects reported the following:
    • In some instances, cancer was detected in patients who had never screened but attended screening as a result of an active reminder by the practice.
    • Many patients, including those who had never screened, were “falling through the gaps” of practice reminder systems.
    • There were certain patient cohorts that were not having screening discussed with them, such as patients with intellectual disability.
    • Patient surveys helped identify simple solutions, such as offering women’s health clinics in the evening, which boosted screening rates and practice revenue.
    • Cleaning patient data revealed lower-than-expected cancer screening participation rates, and identified cohorts of under-screeners.

In the video below, practices that participated in North Coast Primary Health Network’s ‘Women’s Cancer Screening Collaborative’ talk about their experience supporting women to undertake cancer screening. 


The experience of these practices is consistent with the evidence which suggests that, the following primary health activities are associated with increased screening participation5:

recall
Use of recall and reminder systems
endorse
Having a GP endorse invitations to take a screening test
audit
Audit and quality improvement programs

Improving cancer screening participation in the primary care setting

The benefits for your practice

Improved patient experience and outcomes

Cancer screening reduces cancer-related morbidity and mortality by finding cancer earlier than it may otherwise be detected. Early detection can result in patients avoiding radical surgery or adjuvant therapies like chemotherapy and radiotherapy.

NSW general practices that participated in cancer screening quality improvement pilots reported that, the work they undertook directly resulted in early detection of cancer for under-screened patients.

Participants also said that, knowing their work had found a cancer earlier than it may otherwise have been detected was deeply rewarding.

Improved experience of providing care

Quality improvement improves your systems to better support the integrated, pro-active preventative care of your patients.

In 2007, the Institute for Healthcare Improvement developed the concept of the triple aim, which they described as:

  • improving the patient experience of care
  • improving the health of populations
  • reducing the per capita cost of health care.18

Scholars and organisations, including the RACGP, have added a fourth dimension to this aim, which is “improving the experience of providing care”.4,19,20

The activities in this toolkit support your practice to improve its performance against the ‘quadruple aim’ of high quality health care in the following ways:

  1. Improving your patients’ experience of care through provision of appropriate, targeted cancer screening reminders and education.
  2. Improving the health of populations by reducing cancer-related morbidity and mortality through increased screening participation.
  3. Reducing the per capita cost of health care through earlier detection of cancer (when treatment may be less invasive).
  4. Improving the experience of providing care by:
    • providing certainty that practice systems are in place to systematically encourage participation in cancer screening
    • increasing the likelihood that, if a patient is diagnosed with cancer, it is detected as early as possible due to regular cancer screening
    • ensuring you have the knowledge and information resources readily available to support cancer screening education and counselling at the point of care.

Many of the activities that you will undertake as part of this toolkit can be applied to other areas within your practice to improve patient experiences and outcomes, as well as the experience of providing care.4 These activities include organisational changes and improvements, such as:

  • clarification of roles and delegation of tasks
  • development of improved practice policy and protocols
  • strengthened practice registers and reminders
  • improved understanding and application of health literacy principles
  • ongoing quality improvement.

Accreditation

Completion of activities outlined in this toolkit will contribute to Criterion C4.1 – Health Promotion and Preventive Care of the RACGP 5th edition Standards.21

Continued professional development

This quality improvement toolkit may enable your practice team to apply for continuous professional development (CPD) points with your accreditation body. Ask your primary health network representative for more information.

Practice Incentive Program Quality Improvement Incentive

Completing the toolkit activities contributes to your practice’s eligibility for the Practice Incentive Program Quality Improvement Incentive.

Specifically, the toolkit contributes to:

Speak to your primary health network for more information.

Improved business outcomes

Practices participating in cancer screening quality improvement pilots found that the work they did on strengthening their recall and reminder systems (including allocating reminder system tasks across the team) and integrating cancer screening with other patient health checks had a positive impact on practice revenue.

Success in practice:

Success in practice:

Trial Bay Medical Centre found success in a system that involved the practice manager, nursing staff, reception staff and GPs:

“It was a real team-based approach, and we have applied similar processes across other chronic conditions. Our practice is also now generating a strong, ongoing income, with our nursing staff delivering services that are generated out of our recall and reminder system, including health assessments, asthma plans, cervical screening, etc.” 

– Practice Manager, Trial Bay [17]

“Due to our new reminder and follow-up systems, an asymptomatic patient aged 67 years, who had never had a mammogram, presented to BreastScreen NSW after receiving reminders from our practice. She is now undergoing treatment for early-detected breast cancer. In my 18 years of working as a practice manager, and being involved in many different studies and data collection with my primary health network, this would have to be one of the most worthwhile programs I have had the pleasure of being involved in. This is clear evidence that increasing cancer screening participation through quality improvement can (and will) help save lives."

– Practice manager, Tweed Heads17

Common challenges and solutions

The table below lists common challenges when undertaking cancer screening quality improvement and offers strategies for overcoming these challenges.

Common challenges and solutions

There may be resistance within your practice to commit time to team meetings, data cleaning and reminder activities that underpin cancer screening quality improvement.

Strategies that tend to be less preferred by GPs can often be more effective (e.g. practice register and reminder systems, team meetings, appointment of a prevention coordinator).4

Solution:

  • Ensure practice decision makers understand the benefits of quality improvement for the practice, and the activities that will be undertaken. The Module 1 ‘Quick-start guide’ is a helpful and printable summary prior to approving participation.
  • Commit to small, continuous steps. Trying to undertake too much change too fast is overwhelming. It is better to take your time and keep the team on board with change.
  • Communicate, communicate, communicate. Plan how you will engage regularly with your practice leadership and the broader team, both prior to starting and ongoing. Share information and get the team’s input into planned activities, benefits, challenges and progress.
  • Celebrate progress, changes and practice champions.

Solution:

  • Read through Module 2 and establish whether your practice has time to go through patient records to clean up coding mistakes (i.e. errors in how you have set cancer screening recalls).
  • If your practice team decides you do want to retrospectively clean up your patient records:
    • confirm your system for coding results (see Module 2 for more information)
    • identify WHO will undertake the clean-up, WHEN they will undertake it, and agree as a team to give the nominated team members PROTECTED TIME to complete the task.
  • If your practice team decides it does not have time to clean up retrospective mistakes, commit to implementing a cancer screening recall and reminder policy that ensures consistent coding of results moving forward. This will clean data up over time.

Solution:

  • Share and discuss with the team the evidence that reminders from primary care providers increases participation in cancer screening.
  • Share and discuss your practice’s obligations under RACGP accreditation requirements.

Solution:

  • Use the Module work plans for guidance and to document ‘who, what, when, where, how’.
  • As a team, prioritise what actions you want to undertake first.
  • Take one SMALL step at a time.  

Solution:

  • Consider establishing a ‘micro team’ who lead quality improvement in cancer screening participation, but have others from the broader team support components of the work. For example, your practice manager and nurse may be your ‘hub’, but reception staff take ownership of reminders for patients eligible for screening, as well as ensuring suitable promotional materials are available.22

Solution:

Ensure clinical staff are informed about the following:

  • The impact on aggregation of patient data/creation if recalls and reminders are coded/labelled inconsistently.
  • The impact on patient safety and progress monitoring if patient lists/data aggregation is not possible (see Module 2 for more information).
  • Clinician input is important when creating your standardised list for recall and reminders codes/labels. Provide clinicians with easy to access cheat sheets so that they can easily select correct codes/labels.

Solution:

There is a lot of information and resources designed specifically for groups at heightened risk of under-screening, as well as organisations and community groups with whom practices can partner. Module 4 (Care) provides links, ideas and resources for engaging with under-screened populations.

Solution:

Consider developing a cancer screening policy that integrates screening into the templates for existing practice services (e.g. 45 to 49-year-old health assessments, 715 health assessment, ante-natal and post-natal checks and GPMPs. 

  • 6 out of 10 Australians have low health literacy.
  • People with low health literacy find it difficult to understand and act on health information.

Solution:

  • Ensure reminder letters/SMS meet health literacy standards. Module 3 (Connect) will provide you with sample templates that meet health literacy standards.
  • Understand simple health literacy strategies that your practice can use to improve a patient’s ability to actively engage in their own care. More information can be found in Module 4 (Care).
  • Review of Cancer Institute NSW-funded cancer screening pilot projects found that there was often not a strong understanding about Australia’s three population cancer screening programs (for breast, bowel and cervical cancer) within practice teams.17

Solution:

  • The information in Module 1 will support your team’s understanding of:
    • the burden of disease from cancer, and the benefits of screening
    • the basics of how the three population based screening programs work
    • the difference between population based and diagnostic cancer screening
  • Provide your team with information about online learning opportunities.
  • Conduct in-service training.

Solution:

BreastScreen NSW is in the process of rolling out electronic reminders and results.
It is expected that electronic results will simplify the coding of results and the management of recall and reminder systems. It has been confirmed that CAT4 is able to aggregate BreastScreen electronic results.

Patients and practices do not know which ages in the 50 to 74 year age group are being invited.

Solution:

Educate your practice team and patients to use the DoTheTest website to check when an individual will receive their bowel test kit (based on their birthday), and to learn more about the test. 

Note: From 1 January 2019, people aged 50–to74 will receive an invitation every two years around the time of their birthday.

Solution:

GP Assessment Report forms can be downloaded, completed on your computer, saved and/or printed and submitted to the National Bowel Cancer Screening Register by selecting the "Submit" button on the form.