The following section contains suggestions and questions that practices may find helpful to identify areas that could help tackle inequalities along a cancer pathway.

Prevention of Cancer

• Does the practice have any specific groups or populations that may not engage with generic health promotion? Could practices or clusters engage with local health improvement teams to provide bespoke support for these groups? e.g. targeted communication methods or messages, translations of materials, volunteer community champions and supports.
• Are clinicians aware of genetics guidance and referral process? Consider processes to identify high genetic risk patients in the practice population. Enhanced screening and new treatments are available e.g. chemoprevention of breast cancer in high-risk women.

Screening Programmes

There is a Microsoft Teams group with several resources and supports for Equity in Screening In Scotland. The Cancer Research UK Cancer Screening hub has more information and resources and an inequalites in cancer screening guide.

• Address changes and registration process can have impact on screening invitations. For example, younger mobile populations or patients who become homeless. Are address details updated timeously and unnecessary GP registrations minimised. For example, using temporary instead of permanent registration where appropriate?
• Is accessible and translated information about screening programmes available or provided such as a link on practice websites. NHS Lothian website has information videos, easy-read documents, versions in common languages in your area, BSL, a way to request information in braille etc.
• Personalising and endorsement of screening from a recognised clinician increases uptake in patients who do not respond to generic invites. Practices could formulate a template letter, or text message, run monthly searches and merge letters for GP signature to target non-responders.
• Screening “champions” in practice admin teams can assist re-order bowel screening kits, rebooking appts for cervical or breast screening. Ideally local person who has engaged with screening.
• Support local and national campaigns. For example, engage low uptake populations when breast screening mobile unit in practice area. Use of social media to engage families & carers as well as patients. Posters & resources in various language and formats can normalising screening such as “Screening Saves Lives” can be used for practice websites and social media
• Alternative screening arrangements may be required for some patients e.g. interpreters & information in patients preferred format, bariatric equipment, hoists, modified examination couches. Are these options communicated to patients? Is practice aware of screening guidance for transgender patients?
• Opportunistic screening and “teachable moments” giving patients advice increases uptake. Appointments systems can support nursing teams to fit patients in for opportunistic smears
• “Trauma informed practice” Consider any arrangements to support patients with history of abuse or long-term mental health in care settings. Encouraging patients to invite a trusted family member or friend to their appointment and always ensuring appropriate and trusted chaperone is present.
• Choice of appointment times can help engagement. Such as smear appointments during extended hours GP consulting, bespoke smear clinics and drop-in clinics.

Patients with symptoms concerning for cancer: Identification, Safety Netting & Referral

• Promotion of symptom awareness. For patients - “Teachable moments” for and promotion of campaigns (Be the Early Bird). For clinicians using practice meetings for case reviews after diagnoses and significant events. Cancer PBSGL modules and Gateway C
• Communication with local pharmacists can help practices triage and support pharmacist concerns. For example, patients attending with persistent cough, repeat purchasing of supplements, dyspepsia, analgesia treatments.
• Awareness of high-risk groups. Are permanent and sessional clinicians aware of patient groups with high risk of cancer within practice. For example, genetics risks, ethnicity, local employers (ship yards, radiation etc).
• Safety net for high-risk patients. Consider process for high-risk pts who DNA appointments at practice, fail to return samples or DNA following referral. CRUK Safety netting summary and webpage are helpful to support practice processes
• Practice coding of health needs can ensure information is communicated to secondary care at referral. e.g. need for communication support or interpreters, appointment timings to allow carer or family support.
• Complex and non-specific presentations of cancers can be difficult to assess and manage. Practice systems allowing for longer consultation if required can be helpful for clinicians and patients with earlier diagnosis.

Investigation and Diagnosis

• Informing patients of suspected cancer referral: research suggests that providing information regarding a (USC) referral, including explicit use of the word cancer, is considered by a patient to be as important as the speed of their referral. 
• Patients who know they are on a suspected cancer pathway increases patient willingness to travel to first available appointments, change work and travel plans to ensure earliest assessment possible.
• Patient information relevant for patient’s needs can minimise need for repeat testing and re-referral. Patient understanding can minimise, for example, incomplete colonoscopies due to poor preparation, reduce patients opting out or DNA from investigations and appointments.
• Consider if a patient may need support to navigate the diagnostic process? Examples include transport, communication, appropriate appointment times.
• Continuity of care is valued by patients who go on to be diagnosed with cancer. This can be supported by allocating a lead clinician for every patient diagnosed with cancer. Both for communication with patient and secondary and third sector services.
• Holistic cancer care reviews after diagnosis can identify areas of need for patients. Holistic needs assessment can be done by referral to local Improving Cancer Journey teams.

Treatment support
Primary care is less involved during the treatment phase of a cancer journey but can help support during this time.

• Prehabilitation for treatment can improve treatment outcomes. Resources for patients are available either whilst on waiting lists or prehabilitation after diagnosis.
• Cancer Treatment helpline (08009177711) should be used for clinical issues during or within 6 weeks of treatment. Information in patients preferred language and format indicating when and how to access specialist input as well as how to access an interpreter for phone calls can optimise care.

Living with and beyond cancer
On discharge from secondary care follow up patients can feel particularly vulnerable and may need social support, benefits reviews, and support with employment. Primary care and community support can be invaluable. Local community groups are often best placed to meet needs and can work together with specific cancer supports where necessary.

• Consider referral back to Improving Cancer Journey teams for holistic needs assessment
• Consider requesting a “treatment summary” from specialists to help patients and clinicians manage long term symptoms and effects, and awareness of risks from treatment and recurrence.
• Local cancer support charities and services? These are summarised on the cancer card.
• Patients with active and/or advanced disease may need bespoke patient centred clinical and social supports. How are these patients identified and managed? Identifying a lead GP may help with continuity for all patients with cancer.

Palliative and End of Life Care is well documented and summarised in other guidance. Consider how the practice identifies and organises palliative care needs of their practice population.

A whole practice approach to cancer care and awareness can optimise patient experience of their personal cancer care journey. Include the practice team in creating or updating a mission statement for the practice to include principles of inclusivity, accessibility, and equity through relationships of trust and respect.

Staff training and support can optimise the experience and care for patients.

• Does staff induction include cancer conversations such as screening awareness and promotion training?
• Are there opportunities for reflective practice groups & peer support
• Are practice staff supported to engage in their own screening programmes?

Sensitive signposting/resource sharing

• Use practice communication channels with patients to share helpful information on social and wellbeing support in an easy-accessible format? “Cancer support” section on practice website, posters for services and support available in waiting rooms and toilets. Posters in multiple languages and formats where relevant and possible. Facilitate sensitive conversations away from reception desk where possible to maintain privacy.
• Support roles within the practice can optimise cancer care. Community link workers can engage local populations and promoting screening and addressing taboo.
• Resources available to patients and families and awareness amongst all practice staff. Resources and referral pathways are available to anyone affected by cancer, who would like additional information and support? (including third sector and specialist services) e.g. Cancer Card

Practice-based leadership

• Health Equity & Cancer Leads within practices lead development of practice processes, network with community groups and clusters to share learning.

Patient involvement

• Practice data can help identify groups in the area at risk of inequalities.
• Evaluate services with these community groups and work alongside people, from so many backgrounds as possible, with lived experience to plan and you provide?