GP appointment patient

Dr Richard Roope, a practising GP and clinical lead for cancer at Cancer Research UK and the Royal College of General Practice, shares his thoughts on the new National Institute of Health and Care Excellence (NICE) urgent referral guidelines for suspected cancer. These guidelines are used in England, Wales and, to some extent, Northern Ireland (Scotland uses guidelines produced by the Scottish Intercollegiate Guidelines Network).

Each year, as GPs, we see hundreds – if not thousands – of patients with potential cancer symptoms. Thankfully, on average fewer than eight of them* will turn out to have cancer.

The most important way we can help these people is to make sure they’re diagnosed promptly.

Clearly that poses a challenge for GPs – how do we spot patients whose symptoms are most likely to be cancer, among the thousands of others who won’t have cancer, and refer the right ones for diagnostic tests? And how do we do this as quickly as possible?

Today NICE has taken a big step forward towards helping us do exactly that.

Richard Roope - 200px

Dr Richard Roope: “These guidelines have great potential”

It has published new, updated guidelines to help us refer patients with potential cancer symptoms, which now incorporate the latest evidence on exactly the kind of things to look out for. This has been possible partly because of the big jump in available evidence on which symptoms are linked with cancer.

But even better, the guidelines should also give us more freedom to send our patients to see specialists, cutting out delays faced by some patients.

Referring patients sooner has many benefits. It can help reduce the number of GP appointments patients have before they see a specialist, which in turn frees up our time for others.

But ultimately, it could also help more patients to be diagnosed at an early stage, which will boost their chances of long-term survival.

So how will the new guidelines affect what GPs do? What do the changes mean for GPs and patients? And will the NHS cope with the changes?

How do GPs refer patients?

There are many ways that GPs can refer patients – for example, via a routine referral, which comes with a right to start treatment within 18 weeks.

But we have an option that’s specifically designed to diagnose cancer quickly: the ‘two-week wait’ urgent referral route, introduced in 2000. We can use this when a patient has potential cancer symptoms that aren’t immediately life-threatening, but need urgent investigation, and patients referred via this route should be seen by a specialist within two weeks.

By detailing the symptoms most likely to be linked to cancer, the new guidelines help us work out who to refer for further tests and investigations under this system.

But only about 10 out of every 100 patients referred under the two-week wait go on to be diagnosed with cancer. Obviously this statistic is reassuring to anyone we refer for tests, but it also highlights the challenges that GPs, and the NHS as a whole, faces in spotting potential cancer symptoms.

Getting this right is important, particularly in light of recent suggestions that the UK’s lower cancer survival is partly linked to GPs being less likely to refer patients early. And it’s not just about diagnosing cancer – people with these symptoms may well have other illnesses – so referring them quickly will help spot these too, or put people’s minds at rest if it’s something less serious.

And it’s what the public wants too. Research shows that people want to be referred when there is a risk as low as one in 100 that their symptoms could be cancer – despite the inconvenience and/or side-effects that tests can lead to.

What do the new guidelines say?

Click to enlarge or download here

Click to enlarge or download here

NICE now recommends we refer patients with any symptom – or collection of symptoms – that evidence suggests has at least a three in 100 chance of being cancer. There are also some instances where this figure – known as the ‘threshold’ – is even lower, for example when children and young adults have certain symptoms.

For many symptoms, the new thresholds are substantially lower than in the previous guidelines, where the symptoms included rarely went below a five in 100 chance of being cancer.

This gives a clear message to those of us in primary and secondary care that GPs should have more freedom to refer patients. And that’s really important, given the well-documented pressures the NHS is under, as more people are using its services, while belts have had to tighten all round.

We know that quite often, the people who actually do the tests – like endoscopists and radiographers – are really struggling to keep up with demand. Waiting lists are growing and targets are being missed.

That situation – quite wrongly – puts pressure on us to consider not just the benefits of referring our patients, but also whether the system can cope.

So the new guidelines clearly recognise the overwhelming evidence that patients are better served by earlier referrals. The NHS will now need to rise to that challenge.

Will this put more pressure on the NHS?

Overall, as a GP, I very much welcome these new guidelines.

The lower referral threshold means I can send more patients to the specialists who are best equipped to diagnose them. For patients who need specialist care, such as cancer treatment, that means less time is wasted while I carry out tests or have to wait and see if their symptoms won’t go away or get a little more serious.

It will likely mean my patients having fewer appointments before I can give them an urgent referral. It frees up my time for others, and speeds up a patient’s diagnosis.

It could even lead to a reduction from the current figure of one in four patients diagnosed after an emergency – which we know comes with worse outcomes and high costs to the NHS.

So, overall, I think there’s great potential for these guidelines to relieve some of the pressure on services.

Clearly that’s good news for all concerned.

But, of course, there are concerns that the lower threshold will mean many more urgent referrals, which will stretch diagnostic services already at capacity.

That is something that must be accounted for and monitored closely. Referring many more patients, with no changes elsewhere in the system, will put considerable pressure on the NHS. Work must start now to understand how to manage that.

A step on the way to diagnosing cancer earlier

"The people who actually do the tests are really struggling to keep up with demand"

“The people who actually do the tests are really struggling to keep up with demand”

It’s now up to us as GPs, along with those in specialist services and the government, to put these new guidelines into practice. They’re hundreds of pages of long, and it will take a concerted effort to train everyone involved and make the necessary changes to services.

But we also need to see more innovative and joined-up ways to organise cancer services. These sorts of innovations are being examined by the NHS-led ACE programme, supported by Cancer Research UK, and the independent Cancer Taskforce will consider them when their five year strategy for cancer services is announced later this summer.

For the public, the message is unchanged; if you notice persistent or unusual changes to your body then GPs want to see you to check them out. The difference is that your GP will now have more flexibility to get you to a specialist quickly if necessary.

Much more needs to happen to make sure we diagnose cancer as well as the best in the world, but these new guidelines are a very welcome step forward.

The challenge is to make sure that concerns over a potential increase in referrals, as well as financial pressure, does not prevent the NHS from translating these guidelines’ ambition and huge potential into actual benefits for the patients we see every day.

– Richard

*Calculated by the Statistical Information Team at Cancer Research UK using the 2011 UK cancer incidence and NHS workforce data on the total number of GPs in the UK in 2011.