Jumping the queue: could pharmacists help spot cancer?

While as a nation we may love to queue, when it comes to getting suspected cancer symptoms checked out, time is of the essence.

For many of us, this means making an appointment to see a GP and – potentially – being referred to hospital for further tests.

But not everyone is registered with a GP, or has a surgery nearby. Others may worry about wasting the GP’s time or have difficulties making an appointment.

So what’s the best way to help these people get any unusual or persistent symptoms checked out?

One answer could lie with local community pharmacies.

Each year, people in the UK collectively make around 438 million visits to local pharmacies – far greater than the number of times they see GPs.

So pharmacies seem like a good place to reach people who aren’t registered with a GP, have difficulty getting an appointment, or are less willing to talk to their GP.

Recognising this potential, pharmacies have recently been expanding their role in public health and primary care, and there are now several successful programmes to help them do so.

One example is the Healthy Living Pharmacy framework, where pharmacies can sign up to improve the way they run their public health and primary care-related services. Another is our own Talk Cancer training programme, which gives pharmacy staff the knowledge and confidence to talk about cancer with their customers.

But could pharmacists play an even bigger role? As part of the NHS England-led programme to boost early diagnosis of cancer – known as the ACE Programme – Doncaster’s Clinical Commissioning Group (one of hundreds of new local GP-led NHS organisations created after the 2013 NHS reforms) is running a 12 month pilot project to find out.

From September this year, nine pharmacies in the area have been able to send patients with suspected lung cancer symptoms directly to hospital for tests, bypassing the need for a GP appointment

So, how will this work? And will it help more people be diagnosed earlier?

How the pharmacy direct referral to hospital works

During the course of the project, counter staff at participating pharmacies in Doncaster will keep an eye out for visitors who are  current or former smokers, who have certain ‘alarm’ symptoms for lung cancer (such as a cough that lasts longer than three weeks) and who are over 40.

They’ll be particularly on the lookout if such people:

• Regularly or repeatedly buy cough medicines, smoking cessation products or e -cigarettes
• Ask for advice about a cough, pain killers or nutritional supplements, or about giving up smoking
• Collect prescriptions for inhalers

Counter staff can then offer a consultation with the pharmacist who can, if concerned, refer these people directly to their local hospital for tests, without them having to wait for a GP appointment.

Pharmacists can identify and engage with people at a point when they wouldn’t consult their GP

– Rebecca Taylor, ACE programme’s lead for Pharmacy

And as well as offering a new route to cancer tests, the hope is that this will also identify high-risk people who would not normally go to their GP.

As Rebecca Taylor, the ACE programme’s lead for Pharmacy tells us, the potential benefits are clear:

“Pharmacists can identify and engage with people at a point when they wouldn’t consult their GP. This could lead to earlier diagnosis of lung cancer, which means that those people are more likely to be successfully treated.’’

In fact, almost eight in 10 lung cancer patients (77 per cent) are diagnosed at a late stage in England, when the chances of long-term survival are lowest – only 15 per cent of these patients survive their disease for a year or more.

By contrast, among the 14 per cent of patients diagnosed in the disease’s earliest stage, the proportion alive a year later raises to 71 per cent.

So if pharmacists can spot people who might not see a GP until their symptoms become advanced, it might make a dent in these gloomy statistics.

This isn’t the first time this idea has been tested – a shorter (12 week) study was carried out in South West London in 2011-2012. Although it didn’t find any people with lung cancer, it did help diagnose a number of people with other chronic lung conditions, including previously undiagnosed chronic obstructive pulmonary disease (COPD).

The Doncaster project will run for much longer – 12 months – giving it the potential to reach around 68,000 people.

Is it feasible?

Despite the possibility of diagnosing cancers earlier, some have reservations about the idea.

One concern is that, since they don’t have the same clinical training as GPs, pharmacists won’t refer the right people, putting extra pressure on an overstretched NHS and leading to people having X-rays they don’t need.

But as Dr Marco Pieri, the GP leading the Doncaster Project, points out: “You don’t need an in-depth understanding of lung disease to refer appropriately.”

Both pharmacists and counter staff taking part in the Doncaster pilot have had extra training: the latter focusing on the signs and symptoms of the disease, to help identify those who should be referred, while the former focusing on the referral process itself, and the implications of unnecessary X-rays.

We already have some clinical training, and make decisions that will make a difference for patients on a daily basis

– Tosin Sule, a pharmacist at Boots

On top of this, some potential lung cancer symptoms are easy to spot. “Having a cough for longer than 3 weeks is key”, says Dr Pieri.

And pharmacists themselves are also confident they can do the job, as they are already trained to give other similar forms of medical advice and assistance says Tosin Sule, a pharmacist at Boots.

“We already have some clinical training, and make decisions that will make a difference for patients on a daily basis. As pharmacists, we refer patients to GPs anyway, so I believe it wouldn’t be difficult to go one step further and appropriately refer patients to secondary care, as long as the right training was provided.”

While the project was being set up, Dr Pieri also dealt with concerns from other GPs about patients’ care after X-ray.

“These reservations were mainly around the care of the patient after referral. GPs thought that if a pharmacist initially performs the consultation, then they should follow up the care of the patient afterwards – which pharmacists don’t really do,” he says.

To address this, patients will have a follow-up appointment with their GP after their X-ray, for further care and diagnosis.

Widening accessibility

If the pilot proves successful, the main benefit pharmacy referrals could offer is to make it easier for a broad range of people to get the healthcare they need.  A friendly conversation at a local pharmacy could prove to be a really effective way to reach people that are putting off seeing a GP.

As Doncaster Clinical Commissioning Group’s Marie Hancock, says: “It’s about making it as easy as possible for people to get the help they need. And as pharmacies operate long hours throughout the week, including Saturdays, it makes sense to work with them to improve health services for local people.”

Pharmacist referrals can make it easier for people to get the right healthcare in other ways too, especially for vulnerable people who are homeless, or transient and are not registered with a GP.

Rebecca Taylor adds: “Many of the pharmacies taking part in the pilot are in more deprived areas of Doncaster, which have higher than average rates of smoking-related ill health, including lung cancer.

“This means there is arguably greater potential to identify undiagnosed lung cancer or other conditions such as COPD in the local population who visit those pharmacies.”

Will referrals from pharmacies to hospitals get rolled out across England?

While there are no plans to roll this out across England yet, Taylor hopes that the project will generate evidence on the role of pharmacies in helping diagnose cancer patients earlier which, in turn, will help inform future decisions about cancer services.

But some health professionals, like pharmacist Tosin Sule, see it as an obvious move.

“Direct referrals will be good for the NHS. They will decrease the number of GP appointments and improve early diagnosis of cancer, both of which will reduce costs in the long run,” she says.

“It will not be hard for pharmacists to build on the conversations we already have with the public, and make direct referrals part of our everyday tasks. The future of pharmacists is already much more diverse than just dispensing drugs, and I think we can play a far greater role in cancer.”

Pharmacies are increasingly being recognised as a gateway to improving the nation’s health by supporting people to make better health choices; something that was recognised in NHS England’s 5 Year Forward View.

It will be fascinating to see how the Doncaster pilot fares, and we’ll be keeping a keen eye on the results.

Eshe Jackson-Nyakasikana is a stakeholder engagement and communications officer for the ACE Programme at Cancer Research UK

Read more

• The first interim ACE Programme report looking at non-GP referral, which discusses the Doncaster pilot in more detail, was published this week and can be found here.