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Cancer self-referrals made little impact on lung cancer diagnoses

Exclusive The self-referral strategy being trialled by NHS England as a route to diagnosing cancer earlier failed to make any major impact on diagnoses in a previous pilot of the approach, Pulse has learned.

The head of the pilot run in Leeds said that the scheme was successful, but it found that giving patients the option to go directly to hospital for a chest X-ray without first visiting their GP had a small effect on cancer diagnoses.

The findings were revealed after NHS England announced a major new programme of work on improving early cancer diagnosis – including self-referral for chest X-rays as a means of speeding up early lung cancer detection.

One pilot of this planned so far will involve offering people in Crewe from ‘high-risk’ areas the opportunity to request a chest X-ray without a GP appointment.

GP leaders have expressed concerns about the move to bypass GPs and allow patients to self-refer, with concerns it could lead to patients undergoing unnecessary, harmful investigations.

NHS England had said that ‘enabling patients to book their own appointments directly with a diagnostic testing unit or hospital diagnostic service could remove the need for them to see their GP, potentially speeding up the process of diagnosis’.

However, an earlier pilot run in Leeds found the introduction of self-referral chest X-rays had minimal impact on lung cancer diagnoses - although the wider programme of work, of which it was a part, was successful in improving early detection of the disease.

The pilot – set up in 2011 by Leeds Teaching Hospitals NHS Trust – involved three initiatives targeting areas of Leeds with poor health outcomes including high lung cancer mortality, particularly in men.

This involved a ‘Got a cough, Get a Check’ publicity campaign to raise awareness of lung cancer symptoms, alongside a self-referral chest X-ray service whereby people over 50 years of age with a cough lasting three weeks or longer could self-present to a hospital chest X-ray clinic without a GP referral.

The programme – which now forms part of routinely commissioned cancer services in the area – also included a series of GP education sessions on early detection, aimed at lowering the threshold for suspicion of lung cancer and increasing GP referrals for chest X-rays.

Dr Matthew Callister, consultant respiratory physician at Leeds Hospitals Teaching Trust and head of the project, told Pulse the self-referral had been ‘useful’ but that results indicated the self-referral route did not change the way cancers were being diagnosed.

Chest X-ray referrals have increased markedly since the project started, from around 20,000 a year in 2010, to over 32,000 last year. However, Dr Callister explained that most additional X-rays have resulted from the increase in GP referrals with around 2,500 coming via the self-referral route.

And while the provisional data – still being verified by Public Health England before publication -show an improvement in one-year survival from lung cancer, reduced emergency presentations of lung cancer and a small improvement in presenting stage of disease, Dr Callister said most cancers were still diagnosed via the GP referral route.

Dr Callister said: ‘I think the self-referral has been a useful aspect of the programme. We have shown that patients are able to use the service appropriately, and our local GPs have been very supportive of the new pathway. Patients are recalled directly for CT in case of a normal X-ray, and patient feedback has been excellent.

‘However, even with the self-referral pathway, most patients were diagnosed with lung cancer following referral from their GP. Our experience would therefore support introducing a self-referral pathway, but only as part of a wider campaign incorporating GP training, lowering referral thresholds and community education.’

Dr Richard Vautrey, deputy GPC chair and a GP in Leeds, said the earlier pilot cast doubt on the value of self-referral.

Dr Vautrey said: ‘Actually whilst a small number of lung cancers were detected I don’t think they were at a significantly earlier stage than would have been the case from direct GP referrals and so the long term outcome for patients was not that different despite the additional expense.’

Related images

  • outpatient referrals square PPL- online

Readers' comments (6)

  • Numbers might help; How many of the 2500 self referrals resulted in a cancer diagnosis? The tariff for a CXR is about £30 so was that £75,000 well spent and whose budget is it coming out of?

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  • Can we stop pretending evidence and science has any impact here.

    We know virtually all initiatives from NHSE or Public health seem to be coming from their commissars.

    Evidence is inconvenient!

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  • It not only the lack of statistically significant increase in new diagnosis but the cost of radiation in terms of causing new cancers. Was the pilot robust enough to pick up anys tatistical evidence?
    For every 4,000 to 8,000 Xrays, we may cause a new cancer!
    I am not against the original trial but once its thought to be not useful it should NOT be further pushed for political expediency.

    Perhaps its irrational to expect politicians to be rational (TM)

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  • These findings are a shock because??? no one said it would be a failure. Ask doctors on the front line what to do....not your surgeons sitting in ivory towers running tertiary referral centers to have any chance of these things working.

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  • Vinci Ho

    Ha ha ha, told you so.
    With such a massive increase in CXR requests, it is the radiologists NOT respiratory physicians who were working their socks off . I would like to see the comments from these radiologists.

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  • Supplementary question: did the Leeds pilot lead to a significant increase in the detection of TB?
    Should we focus entirely on lung cancer, when TB is also a major, possibly more important issue?

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