Early Diagnosis of Cancer Significant Event Analysis Toolkit


Cancer SEAs prompt a GP to reflect on their diagnosis, and identify any potential improvements in practice systems using documentation or proactive safety netting.

At CCG or Health Body level, a cancer or quality improvement lead may find emerging themes and use local intelligence to address and manage issues. Cancer Significant Event Analysis (SEA) can support dialogue between the primary and secondary care interface and have benefits for clinicians, practices and patients.

Who is the toolkit for?

This cancer SEA toolkit and its resources support GPs, practice staff and commissioners in conducting high quality cancer SEAs with the aim of improving patient outcomes in the early diagnosis of cancer.

This toolkit may be used by CCG/Health Body or cancer leads, practice GP leads or any GP in practice delivering training and includes guidance for quality improvement across the primary secondary care interface.

If you are based in England or Wales and interested in your practice taking part in the National Cancer Diagnosis Audit, please find out more and register here. Note that the audit in Scotland has now closed.

Training resources for cancer/commissioning leads

The following resources have been developed with a 'train the trainer' approach as a guide to the process involved in completing an effective SEA.

  • What is a cancer SEA? This info sheet looks at the cancer SEA process, the questions it should answer, its components, and implementation in a practice setting.
  • Process flowchart This flow chart shows a continuous cancer SEA Quality Improvement process that may be implemented in your CCG or Health Body.
  • Case selection Info sheet on the importance of case selection for a cancer SEA and tracking a practice's cancer activity.    

How to undertake a high quality SEA

These resources and tools can aid in the undertaking of a high quality Cancer SEA. They include cancer SEA template, instructional video and info sheet on using the template.

The feedback instrument tool

  • feedback instrument tool (2015) was developed by Macmillan and RCGP. This tool can be used by individual GPs or practice teams to self-appraise their cancer SEAs. Guidance for peer-reviewers is included.


  • This 'Analyse Themes' info sheet helps explore whether reflection has been extensive and identifies themes that could have been discussed or actioned more effectively.

Actions and impact

  • This 'Actions and Impact' info sheet looks at how employing effective team meetings, agreeing actions, and measuring impact are a crucial part of the cancer SEA.

Quality Improvement

To access shared learning networks to assist you in applying practical QI methodologies to better treat this clinical area, join our QI Ready platform.

Examples of SEAs with thematic analysis

The following fictional example cancer SEAs demonstrate a varying range of quality. Each contains detailed notes showing both positive and negative examples of reflection, subsequent actions, and impacts following a cancer diagnosis.

The three examples are centred around colorectal and ovarian carcinoma, two cancers known to present as an emergency.

  • SEA Patient A An example where reflection could have been deeper.
  • SEA Patient B An example describing a clear timeline of events, however it could demonstrate deeper reflection, more specific learning action points, and the impact on practice.
  • SEA Patient C An example which is thorough in its discussions and demonstrates insightful reflections, specific learning and action points.

These fictional examples can be used to demonstrate best practice in cancer SEAs, and where improvements can be advised to GPs.

Resources and guidance for training practice staff

The Cancer SEA GP guide can be used by any GP wishing to undertake a Cancer SEA. The guide can also be issued as a 'hand-out' for GPs in your training events.

'Early Diagnosis of Cancer - Quality Improvement Using Cancer Significant Event Analysis' training session resources

The following resources consist of a presentation that can be adapted for your training events, and resources to support this:

Resources for training sessions:

Safety netting in primary care

Safety Netting may support healthcare professionals to detect cancers earlier and minimise delayed diagnoses. It is a technique which can be used to ensure the timely re-appraisal of a patient's condition. This is important for conditions such as a suspected cancer where patients present infrequently with common and often non-specific conditions.

Safety netting resources

The following presentations were developed for this toolkit but can be adapted and used as needed. They contain detailed information, background and tips on safety netting, why and how to use it, and information on coding. These may also be used or adapted in a training context.

Safety netting background information

Additional cancer risk assessment tools

  • Cancer Decision Support (CDS) tool The CDS tools are designed to support GPs in their clinical decision making and encourage them to think cancer by displaying the risk of a patient having an as yet undiagnosed site-specific cancer. This risk is based on read coded information from their patient record including symptoms, medical history and demographic data and uses either QCancer or RAT to calculate the score. To find out more, including whether the CDS tool has been integrated in to your IT system, please visit the CDS Promotion Pack

  • QCancer calculates the risk of a patient having a current but as yet undiagnosed cancer, taking account of their risk factors and current symptoms. This tool is designed to support clinical decision making and does not replace clinical judgement.

  • Cancer Risk Assessment tool (RAT) is an algorithm that can be used to calculate the absolute risk that a patient has an undiagnosed cancer based on certain risk factors and their current symptoms. The RAT is designed to support clinical decision making and does not replace clinical judgement.

    For more information on prevention, screening and treatment of cancer in primary care, please visit the Primary Care Cancer toolkit. For further information on identifying and managing the consequences of cancer treatment, and supporting patients to live well after a diagnosis, please visit the Consequences of Cancer toolkit. For specific referral guidance, please visit the Brain Tumours in Children toolkit.

Background and rationale

Project Background

With funding from NHS England and Macmillan Cancer Support, and developed in partnership with the Clinical Innovation and Research Centre (CIRC), this toolkit combines a body of work to assist general practices. The toolkit is also applicable to devolved nations.

This report reviews the project and its impact


  • Steering committee members
  • London Cancer
  • Transforming cancer Services Team Healthy London Partnership
  • NHS Gloucestershire CCG
  • NHS Birmingham Cross City CCG
  • NHS Education Scotland
  • University of Leeds
  • The Hull York Medical School

Information for Commissioners

The Cancer Task Force published Achieving World-Class Cancer Outcomes - A Strategy for England 2015-2020. It contained 96 recommendations across primary, secondary and public sectors. Recommendation 25 stated GPs should be required to undertake a Significant Event Analysis for any patient diagnosed with cancer as a result of an emergency presentation. The SEA template used for this project is the ideal quality improvement tool to implement this recommendation.

A key part of the strategy includes reducing emergency presentations of a new diagnosis and deciphering whether there are specific avoidable contributors; currently just over 20 per cent of all cancers in England present via this route. This Cancer SEA Quality Improvement toolkit for the Early Diagnosis of Cancer can be used to support CCG/Health Body cancer leads and Macmillan GPs to deliver localised schemes aligned with the cancer strategy and embed their use alongside safety netting and risk assessment tools to improve early diagnosis.

Background on Cancer SEAs

Significant Event Analysis (SEA) is an approach to quality improvement now well-established in general practice. It involves a structured review of all that happened in relation to the event of interest, which may be adverse, exemplary or simply important. The requirements of the Care Quality Commission, annual appraisal and revalidation are increasing emphasis on the quality of continuing professional development and reflective practice.

Between 2009 and 2012, the RCGP in collaboration with NCAT and the Department of Health developed a cancer-specific SEA template as a quality improvement tool with accompanying advice on its use. This proved popular with practices and cancer networks. The template was designed to support GPs to not only complete a quality cancer SEA to a high standard but also as a real vehicle for change with an emphasis on reflection with a non-judgmental approach.

The RCGP has produced a Quality Improvement guide for General Practice to support the whole primary care team on their quality improvement journey. 

The RCGP and Macmillan Cancer Support have continued to champion the use of cancer-specific Significant Event Audits with respect to early diagnosis. In 2014 the RCGP partnered with Macmillan Cancer Support to train appraisers to effectively appraise Cancer Significant Event Audits in a way that supports quality improvement in patient care. In this initiative, systematic peer review was incorporated under the imprimatur of the RCGP, in a pilot that was promoted through cancer networks.

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