Imagine over a 3 week period you experience unexplained weight loss and bowel problems.
You go to your GP and you’re referred to a local hospital to be seen by a specialist.
4 weeks later the specialist sends you for a colonoscopy – a test that looks at the inside of the large bowel. And while waiting for the test the following month, those symptoms continue.
If the GP felt the symptoms were more urgent, you could have been sent to a specialist via a 2 week urgent referral.
But all in all it takes 9 weeks from originally seeing the GP to getting the results of the test.
It’s at this point you’re diagnosed with bowel cancer.
The question is: could this hypothetical tumour have been discovered sooner? And if so, could this be done without simply sending everyone who walks through a GP’s surgery for urgent tests?
A series of projects run through the ACE programme, an NHS England early diagnosis initiative supported by Cancer Research UK and Macmillan Cancer Support, are attempting to find out.
And they’re focusing on an approach called direct access.
A GP’s options
GPs play a vital role in helping diagnose cancers earlier and reduce the time patients have to wait to start treatment.
Though a GP will only see a handful of people with cancer a year, they will see many more who are experiencing concerning but non-urgent symptoms that could be the early signs of cancer.
So when a patient in our hypothetical situation visits their GP, what options does the GP have? They fall into two main categories:
- A routine referral – the patient will first attend an appointment with a specialist, where they are assessed and sent for a diagnostic test if needed. Patients are entitled to receive any treatment they may then need within 18 weeks.
- Straight to a test – for more urgent symptoms the GP can refer the patient straight for a diagnostic test at a hospital. If a patient is diagnosed in this way they will typically start treatment sooner than via the routine referral because the first hospital appointment is avoided.
What is direct access?
Even though the symptoms in our hypothetical scenario were serious enough for the GP to send the patient to a specialist, they weren’t specific enough to suggest the need for an urgent referral.
One possible way of handling these challenging cases is through direct access – a variation of the second option GPs have.
This doesn’t involve being seen by a hospital specialist first. Instead, the patient is referred by their GP straight to the appropriate diagnostic test (such as a colonoscopy).
And because the patient isn’t seen by a hospital specialist first, the GP retains responsibility for the patient.
In exceptional circumstances where a cancer is diagnosed, arrangements are made then for further tests and treatment. But in most cases, the patients are discharged back to the GP.
Does it work?
The projects funded through the ACE programme are looking at whether the direct access approach could help GPs handle patients with vague symptoms that may be linked to cancer.
There are projects looking at the approach in patients who are suspected to have lung or bowel cancer.
And another project in Yorkshire is exploring an innovative new computer-based system where GPs receive advice about the diagnostic tests a patient should have from specialists.
The GP can use the computer system to send a report to a radiologist to review. And the radiologist will advise which imaging test is most appropriate for the patient within 48 hours.
Both patient and GP feedback so far has been very positive
– Dr Helena Rolfe, project lead and GP
This is being tested in 17 GP practices, and so far 12% of patients referred via the system have been found to have cancer compared to the average of 10% of patients diagnosed through urgent routes.
The project also shows promising signs for the speed of diagnosis. All patients found to have cancer were diagnosed within three weeks from their GP referring them.
For Dr Helena Rolfe, the project’s lead and a GP, successes are already beginning to shine through.
“The best thing about this system is that GPs have assurance that after consulting with the radiologist, the patient will have the most appropriate tests fast-tracked through the system,” she says.
“Both patient and GP feedback so far has been very positive.”
But these projects aren’t the first time this approach has been tested.
Direct access isn’t new
The Department of Health committed additional funding for tests back in 2011.
But little evaluation on the impact of direct access has been done.
And while almost all GPs in England can refer patients for tests such as chest X-ray and ultrasound, rates for other tests are generally much lower.
An Oxford University survey found that of 511 GPs just over half could directly refer patients for a CT scan. And referrals for other tests varied between regions, with just 7% of GPs in Wessex having access to CT scans compared to 95% of GPs in the West Midlands.
And the opportunity to directly refer patients for endoscopy remains generally low across England, with just 42% of GPs surveyed having access to flexible-sigmoidoscopy and 32% having access to colonoscopy.
Challenges that direct access brings
More referrals also bring challenges to already stretched diagnostic services, which we’ve blogged about before.
The NHS in England has acknowledged the rising demand for diagnostic tests in its recent cancer strategy implementation plan. And this includes setting up a fund to identify ways of managing the demand.
The English government has also pledged to train 200 more non-medical endoscopists, which should help to ease pressure on specialists.
But with over 200 different types of cancer, no single way of diagnosing people is going to be effective for everyone. And that’s true for direct access.
Our research is showing that it may not be the best option for cancers such as lung, where symptoms often appear later than for other cancers. There are also a wider range of symptoms that overlap with other chronic diseases.
Direct access also relies on GPs having the knowledge and confidence to choose and refer patients who have non-specific symptoms to the right test, first time.
But in bowel cancer it’s showing promise. Two projects in London have seen the approach reduce waiting times. And patients seem to be happy with the experience.
By eliminating that first hospital appointment, the approach has also freed up time for doctors and nursing staff.
Later this year, the ACE programme is testing an alternative way to diagnose patients with vague but concerning symptoms. Instead of direct access, where the GP refers a patient for a specific test, GPs can instead send patients to a centre with a range of diagnostic tests and a range of specialists.
We’ve blogged about these Multidisciplinary Diagnostic Centres before.
And if successful, this could offer an alternative for cancers where direct access may not be suitable, easing pressure on a stretched health service.
But for now, direct access offers GPs and patients a possible way to get the right diagnostic test, as fast as possible.
Edmund Fuller is an engagement and communications officer at Cancer Research UK
If you’d like to keep updated on the results from the ACE projects, email the team on [email protected] to sign up to the newsletter.
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