GatewayC: Improving early detection of cancer through e-learning for primary care

GatewayC aims to support the objective of improving patient outcomes by increasing compliance with NICE guidance on recognition and referral for suspected cancer and reducing the number of patients presenting with cancer through routine referral and A&E.

GatewayC aims to do this by:

• Supporting GPs in identifying patients with potential cancer symptoms
• Increasing GP confidence in decision making relating to use of the suspected cancer referral pathway
• Improving patient experience by helping GPs to prepare patients for suspected cancer referrals and tests

These aims support the guidance within NICE [NG12] and are also applicable to a number of cancers listed within the guideline (lung, colorectal, pancreatic, lymphoma, myeloma, and brain tumour) with additional cancers within the guideline to be developed into GatewayC courses at a later stage.

The GatewayC team set out to create an educational platform to meet the above aspirations. By creating the educational environment online, it can address the rarity of cancer in the average GP workload and ensure that GPs have access to high quality learning and support when they need it.

Educational content includes filmed, interactive video consultations based on true patient experiences. Users are introduced to a wide range of ‘characters’ with differing patient profiles, histories, comorbidities and emotions. Reflective activities along with other quizzes and exercises put clinicians at the heart of the learning and reinforce clinical decision making around which patients require referral. Activities are complemented by interviews with clinical oncology specialists to further support the key messages within each course.

GatewayC is accessible, usage and feedback can be analysed for local reporting purposes and the platform has the potential to be scalable across the whole NHS. 

Over 30,000 people each year are diagnosed with cancer; a number that continues to rise. Nearly half of these people will have a late stage diagnosis, meaning their chances of survival are greatly reduced, their treatment is harsher (and more costly to the NHS) and survivors can experience significant long-term complications, devastating their quality of life. 

Over half of GP practices in Greater Manchester, where GatewayC was first developed as a pilot programme, have suspected cancer two-week-wait referral ratios below the England average, with many patients reporting 3+ visits to the GP before referral. To reduce the number of multiple appointments prior to referral and improve referral ratios in line with NICE guidance, GPs need access to good quality, evidence based, and behaviour changing education, available when they need it. 

An opportunity also existed to improve the quality of suspected cancer referrals, to ensure patients are referred appropriately but not over-referred, to avoid clogging up the system with unnecessary referrals but speeding up diagnosis for cancer patients – also saving money on long-term treatment.

GatewayC has worked with a range of stakeholders including primary and secondary care, charities and user representatives, both to scope the wider programme and to feed in to each cancer course. Cancer Research UK are involved in the quality assurance process of each cancer course, with user representatives from Macmillan feeding their own experiences into each course to ensure that it is truly reflective of patient need.

GatewayC users are asked to complete both pre and post-course confidence assessments to measure learning impacts. They are also asked to complete action plans to demonstrate how they will put GatewayC learning into practise. The software used to host GatewayC also allows the team to analyse statistics including how many primary care staff are accessing the education, which CCGs they are visiting from and which cancer courses they are completing.

Due to the online nature of the education, it is not limited to a single catchment area and is currently being rolled out across a number of cancer alliances in England.

Defined learning objectives were set and agreed in the development of each cancer course, including referencing NICE guidance at the point of scoping. Clear learning regarding red flag symptoms, suspected cancer referrals and communication with patients is included in each cancer course. Some courses also include quizzes specifically testing knowledge of NICE guidance for a particular cancer pathway.

 GatewayC engages a wide number of stakeholders in its development including primary care, secondary care, user representatives and charities. This process is complex and therefore the programme has a clear development roadmap for each new course. It also defines clear learning objectives at the outset of each course, to ensure that these are adhered to and met with the final product. Furthermore, each cancer course is quality assured internally and also externally by Cancer Research UK, to ensure that it meets the initial objectives and is relevant, clinically accurate and appropriate education.

 GatewayC is a not for profit programme designed by the NHS, for the NHS. There are some costs associated with the development and day to day running of GatewayC. These include development costs, operational costs, design costs and marketing the resource effectively to primary care. Additional information on costings is available on request. The project was originally funded by the Greater Manchester Cancer Vanguard Programme and is currently funded by Health Education England.

GatewayC conducted a pilot study across Greater Manchester and in parts of London, publishing results in November 2017. It continues to evaluate progress via user feedback and evaluations and online surveys. Results from the pilot study demonstrated:

• 94% of users reported learning from GatewayC would help with future referrals
• 85% of GP users reported improved recognition of symptoms meriting a suspected cancer referral
• 85% reported increased confidence in knowing when to refer a patient on a suspected cancer referral
• 75% reported improved confidence in when not to make a suspected cancer referral
• Results also suggest that GatewayC changes GP attitudes when preparing patients for referral. Users reported feeling more confident in communicating with patients about their referral and mentioning cancer. This will prepare and support patients, and improve their experience of the process.
• Some GPs also reported recalling certain COPD patients for review during the study as a direct result of completing the GatewayC lung cancer course.

These results show evidence of improved practice and prove GatewayC’s relevance in a clinical setting.

In addition to the pilot results, GatewayC has received excellent feedback from GPs, user representatives and industry representatives alike. 

 “I have spoken to a number of my GP partners who have also completed the learning modules, and they all agree that this has been one of the most useful educational experiences they have had. There is evidence that the learning has ALREADY begun to change practice.” – GP user

"I could quite clearly see that if this [GatewayC Colorectal] course was available for the doctors at the time that my cancer was diagnosed, it would not have been missed." – Saeed Shakibai, user representative

"GatewayC has been created as a 'go-to education site', especially tailored to address the needs of the Cancer Plan; it aims to help GPs improve recognition of potential cancer symptoms, support patients and develop decision making about referral." - Professor Chris Harrison, National Clinical Director for Cancer

GatewayC currently has over 1,500 users and this number continues to grow. Health Education England has funded for GatewayC to be available for all primary care staff across the north of England. Several cancer alliances in the south of England have also rolled out GatewayC to their primary care staff.

It is paramount to have clear learning objectives and to place the clinician at the heart of the learning, to reinforce clinical decision making that will then translate into general practice.

Results from the pilot study, along with ongoing feedback from post-course surveys, indicates that users find the interactive consultation videos the most useful part of our educational courses.

GatewayC presents each cancer course with a range of interactive videos, quizzes, case studies, specialist interviews and other exercises that are designed to engage the user to actively apply key learning objectives. As a result of this, the development of each course is complex and involves a range of stakeholders including general practitioners, secondary care professionals, user representatives, charities and actors. In order to ensure that resource and time are both used effectively and to ensure that learning objectives are met, GatewayC has developed a structured development process for each course, with clear outcomes agreed from the outset. In addition to a structured development process, GatewayC also incorporates quality assurance into the delivery of each cancer course, to ensure clinical relevance and a high quality product. This includes an external quality assurance process, via Cancer Research UK.

Education providers should continuously improve to ensure that primary care staff continue to engage with the platform and apply the key learnings into general practice. Most recently, GatewayC has developed a user-friendly action plan which is incorporated into each cancer course. This encourages users to set their own objectives to take into their day to day roles. As a bonus for users, this has been designed in such a way that it can be easily downloaded in a user-friendly format, for use in personal development plans and annual appraisals.