GM Cancer Personalised Care Standards for Primary Care - v1.4 - implementation guidance

Sep 15, 2026

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GM Cancer Personalised Care Standards for Primary Care set practical expectations for delivering cancer support discussions and Cancer Care Reviews (CCRs) within defined timelines after diagnosis. The standards cover proactively offering support within 3 months, arranging CCRs as pre-booked standalone appointments within 12 months, and ensuring reviewers have appropriate training and are competent to inform and signpost patients. Requirements include structured electronic recording, minimum review duration, optional questionnaire preparation, access to the End of Treatment Summary, and follow-up CCRs as part of ongoing care.

LanguageEnglish

CategoryLetters

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Standards

Cancer support discussions and timing

Cancer Care Reviews (CCRs)

CCR preparation, delivery, and recording

Follow-up CCRs and continuity

Resources

GM Cancer Personalised Care Standards for Primary Care 1. Practices should have a robust system for proactively offering cancer support discussions (CAN005) within 3 months of diagnosis and cancer care reviews (CAN004) within 12 months of diagnosis 2. Patients should be sent a letter following a new cancer diagnosis explaining what support is available to them. With the help of primary care and patient representatives, GM Cancer has co-created a letter template for practices to use (see Resource 1). This will be added to your clinical system as a template. Please feel free to change the wording to make it specific to your practice and to include additional local services. 3. Cancer care reviews (CCRs) should be undertaken by a member of staff who has had appropriate training (see Resources 4-6) and feels competent to provide information to patients living with cancer and signpost to appropriate colleagues and local partner organisations. This could be a practice nurse, GP, primary care cancer care coordinator, social prescriber or another member of the practice/PCN team whois deemed competent and has been appropriately trained to undertake CCRs. 4. A CCR should be a pre-booked and standalone appointment and not included as part of an existing consultation. 5. Although CCRs can be completed any time within 12 months of diagnosis, the specific timing of a CCR should be decided by the patient based on when they think they will benefit most from it. This is normally not within the first few months after diagnosis as patients will have holistic support from their hospital specialist team. 6. As these are individualised reviews, they will take variable lengths of time. However, the minimum time offered to the patient for their CCR should be 20 minutes. These can be done face-to-face, telephone or video consultation, based on patient preference and their specific needs. Patients should also have the opportunity to bring a friend, relative or carer with them to their appointment if they wish. 7. Patients should have the opportunity to prepare for a CCR by completing an appropriate questionnaire to help them think about the concerns they wish to discuss in advance of their appointment (see Resources 2 & 3) . 8. Where available, healthcare professionals completing a patient’s CCR should have read their End of Treatment Summary (EoTS) from their specialist team, as well as any other relevant clinic letters, to promote continuity of care. 9. CCRs should be recorded onto a patient’s electronic medical record using a structured template. The Macmillan Cancer Care Review template is available on EMIS, SystemOne, Vision and Ardens. A copy of the review should also be offered to the patient after the appointment (printed and/or electronic) . 10. A CCR should be the start of a continuous process. Follow-up CCRs should be offered when required or requested and should be considered as part of a patient’s subsequent annual chronic disease reviews. CCRS v1.4 Nov 2023 Review Date: Nov 2025 Resources 1. GM Cancer New Cancer Diagnosis Letter Template (attached) 2. AccuRx Cancer Care Review Questionnaire (Florey) 3. Macmillan Concerns Checklist (printable version) 4. Red Whale Personalised Care Training Video (30 minutes) 5. Macmillan Cancer Care Review Online Course (free registration required) 6. Personalised Care Institute eLearning Modules CCRS v1.3 Sept 2023 Review Date: Sept 2025

FAQs

When should cancer support discussions and CCRs be offered after diagnosis?

Support discussions should be offered within 3 months of diagnosis, and CCRs should be completed within 12 months. The exact CCR timing should be decided by the patient based on when it will benefit them most.

What must be true about how a CCR appointment is scheduled and delivered?

A CCR must be a pre-booked standalone appointment, not added to an existing consultation. It should be delivered by appropriately trained and competent staff, and offered for at least 20 minutes via face-to-face, telephone, or video consultation based on patient preference.

How should CCRs be prepared, documented, and shared with patients?

Patients should be able to prepare using an appropriate questionnaire. Clinicians should read the patient’s End of Treatment Summary and other relevant letters to support continuity, record the CCR in the electronic medical record using a structured template, and offer the completed review to the patient after the appointment.

Sep 15, 2026

Upload by Jiven