The NHS is expected to find efficiency savings of £22 billion over the next four years or so. As well as implementing new structures and coping with the potential financial fallout from Britain’s exit from the EU, it is also expected to perform better in many sectors in terms of health outcomes. One such area is cancer diagnosis, treatment, and survival.
Assuming that cancer statistics between European countries are comparable and equally valid, then the UK is a consistently poor performer when it comes to cancer care. There is a drive for earlier diagnosis and treatment in the hope and belief that it will improve survival. To try to improve the quality of care is obviously laudable, although I am somewhat pessimistic about the ability of the NHS to improve within the context of a static or shrinking budget.
The NICE guidelines for cancer referral have been updated in the past year or so as part of this drive. Prior to this it was estimated that GPs should have an index of suspicion that translated to 5% of patients referred on a fast track cancer pathway eventually receiving a cancer diagnosis. Now GPs are being asked to change the positive predictive value threshold for referring patients on the two week urgent referral pathway to 3% rather than 5%.
In effect, when this is calculated after the event, it is our cancer “hit rate” that is being measured and our new target is to lower our suspicion for cancer so that we have a “hit rate” of 3%. This is just one of the many parameters that is being measured and monitored and fed back to GPs. For you to have a hit rate of 3% then you need to refer more. However, if you refer more you may well catch more cancer, and so you have to refer even more to bring your hit rate down, a potentially ever expanding problem if yet more cancer is detected, buoying up your hit rate.
To put it another way, we were, as GPs, being expected to refer 20 patients for every new diagnosis of cancer; now we should be referring 33. If our hit rate was as low as 5%, then we are now being asked to increase the number of referrals by around 65%. In reality, practices across our area have a “hit rate” of around 7%. One could consider that we are doing a good job in identifying the correct patients to refer to a secondary care system that is also struggling, as we are, to cope with demand. However, to meet the target of lowering our hit rate, collectively we need to refer at least double the number of patients.
Our practice would need to refer about 200 more patients for a fast track appointment to rule out cancer each year, or an extra four patients each week. Across the clinical commissioning group (CCG), if all practices were to increase their referral rate, it would mean an extra 21 000 referrals into fast track clinics. As a GP I currently have no idea if our local hospitals have the staff, funding, and space to cope with double the volume of work, or the opportunity cost of diverting resources from other services.
The potential problems are not just with the volume of work being transferred to secondary care, but with the consequences for both GPs and patients of lowering the referral threshold. In my short experience as a GP, I would say that patients and families who have been referred to secondary care or for investigations are more likely to keep coming back for the same kind of reassurances.
In other words, I doubt whether referral for reassurance actually works, and it likely exacerbates any health anxiety that might be present. I have been castigated by a patient before for referring him to a fast track colorectal clinic when he fulfilled the criteria, but no cancer was found. He was angry at the amount of anxiety I had caused him. The costs of such anxiety probably can’t be calculated but seem not to have been taken into consideration.
Lastly, creating a mindset within GPs that league tables of referral patterns will be used to assess their performance is likely to mean that we become more defensive; refer more; use time as a tool less appropriately; and create anxiety among our patients by virtue of the fact that the potential diagnosis, which previously lurked at the back of our mind, is now shouting loudly at the front of our consciousness.
The victims of the battle against cancer will be many unless primary and secondary care receive a funding boost. Firstly, to secondary care so that its capacity to handle fast track referrals doubles. And, secondly, to general practices so that GPs can spend enough time with our patients to explain our referrals and deal with the aftermath of them being deemed unnecessary, or do I mean successfully wrong?
Samir Dawlatly is a GP partner at Jiggins Lane Medical Centre and board member of Our Health Partnership. The views expressed here are his own and don’t necessarily represent those of any organisation he works for.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: I am a GP partner at Jiggins Lane Medical Centre and managing partner and board member of Our Health Partnership. I am the co-clinical director of the QCAPS referral management scheme for Northfield Alliance Ltd. The views expressed here are my own and don’t necessarily represent those of any organisation I work for. I am an occasional member of the RCGP online working group on overdiagnosis.