Background Two million people in the UK live with cancer: this will double by 2030. Research which tests a primary care model of supporting this growing population from diagnosis to palliation is urgently required.

Aim To assess the feasibility of active follow-up of patients in primary care from cancer diagnosis onwards.

Methods A two phase, mixed methods, action research study. An electronic Cancer On-going Review Document (CORD) was first developed by patients and professionals, for use with all patients with a new diagnosis of cancer. This was evaluated through record review, qualitative interviews with patients, family carers and health professionals, and documentary analysis of the CORDs. Interviews were recorded, transcribed and entered into NVivo for thematic analysis, and numeric data analysed using SPSS.

Results The records of 106 patients from 13 practices were examined, and 45 interviews conducted. CORDs were usually used only once (range 1–9 times), but when used prompted clear and often graphic documentation of multi-dimensional needs and understanding. General Practitioners felt it helped to structure consultations and cover psychosocial areas. Few discussed the review openly with patients, and the template was often completed after the consultation. Patients and carers valued a palliative care approach from primary care, which was seen to offer holistic care and close relationships, and from early in the disease trajectory.

Conclusions This tool is unintrusive and patient centred, promoting continuity of care and holism. If more on-going care for cancer patients is to be delivered in the community in a chronic disease model, this template may be useful but needs to be better integrated and incentivised within practice IT systems. A care framework akin to other chronic illnesses such as Diabetes, which uses specific templates is possible in primary care, but needs to be integrated and prioritised.