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Urgent GP cancer referrals bounced back as hospitals try to manage demand

Exclusive Urgent GP cancer referrals sent via the two-week wait pathway are being ‘bounced’ or downgraded to non-urgent, in some cases leading to delays in cancer diagnoses, Pulse has learned.

Local GP leaders have told Pulse they have had direct experience of urgent cancer referrals being refused, or moved to routine referral pathways by local or hospital referral management panels trying to limit the number of referrals into secondary care.

In some cases, patients have subsequently been diagnosed with cancer, raising the possibility their outcomes have been worsened as a result of the delay.

The concerns come at a time when GPs are facing increasing scrutiny – and blame – over delays in cancer diagnoses.

Earlier in the year, health secretary Jeremy Hunt announced individual referral data would be published to ‘red flag’ GPs who did not refer cancer cases promptly, while practice-level data on cancer diagnoses published on the NHS Choices website were reported as showing GPs were not referring  cancer cases urgently.

New draft guidelines published by NICE last month have proposed lowering the risk threshold for cancer referrals, broadening the circumstances under which GPs are expected to refer urgently to a specialist – meaning, for certain cancer pathways, outpatient referrals are expected to increase significantly.

However, information passed to Pulse indicates that GPs are already unable to refer some cases they feel should be seen urgently through the two-week wait pathway.

In one example, Dr Gillian Breese, a GP in Llandudno, Wales, said a man referred urgently with suspected bowel cancer was not seen by a consultant within two weeks but was instead redirected for ‘urgent’ colonoscopy, facing a wait of 25 weeks.

The patient decided to be seen privately by a consultant to speed up the investigations and was confirmed to have cancer.

Dr Breese explained: ‘The case was an elderly male referred urgently with suspected bowel cancer. He came to see me not long after referral with a letter from hospital stating he was being listed for urgent colonoscopy and that current waiting time for this was 25 weeks.’

She added: ‘His decision to have consultation and colonoscopy privately much quicker may have changed his eventual outcome, as after a 25-week wait on NHS the prognosis may have been very different.’

CCGs are increasingly relying on referral management panels to manage demand on specialist clinics, using locally agreed referral criteria for urgent cancer pathways based on NICE recommendations.

But according to the current NICE guidelines, GPs can still refer someone to a specialist if there is ‘a possibility of cancer’ even if the patient does not fit a specific profile – and they should also refer people urgently if investigations cannot be done urgently locally.

Similarly, the new draft guidelines published last month emphasise: ‘These recommendations are recommendations, not requirements. They do not over-ride clinical judgement.’

However, Dr John Ashcroft, an executive officer at Derbyshire LMC, told Pulse urgent GP referrals were ‘absolutely’ being turned down and that he had recently had a case completely refused.

Dr Ashcroft explained: ‘Absolutely this is happening. If a case doesn’t quite fill the guidance for two-week referral even though clinically you think it is important it gets bounced and you have to make a normal referral.

‘About a year ago a case I felt to be a two-week ended up being bounced, he didn’t quite fulfil the criteria but he had this niggling pain – abdominal discomfort. It was still there two months later, [the specialist] then arranged a CT scan – which I couldn’t do, I would have done straight away if I could – and of course he turned out to have cancer.’

Elsewhere Dr John Hughes, chair of the association of LMCs in Greater Manchester, said concerns had been raised with GP leaders in his area that cases were being refused or downgraded without sufficient clinical input.

Dr Hughes said: ‘In some cases it appears that is the consultants who view them and decide [to refuse] but there have also been concerns expressed that in some cases it is non-clinicians, because most of the referral management centres do not have a heavy clinical input.’

According to Dr Ashcroft, referrals were being rejected because CCGs in some areas had tried to limit referrals without investing in alternative pathways, for example to boost GP direct access to diagnostic tests such as ultrasounds.

Dr Ashcroft said: ‘With CCGs being set up it was all about “you’re going to try to reduce referrals so we have more money to do things differently” – but “different” never happened and you can only limit referrals so much.’

He added: ‘It’s a cultural thing – the entire culture is very negative about general practice and we don’t get the tools. They need to invest but also put the capacity in the right place.’

Professor Greg Rubin, professor of general practice and primary care at the University of Durham and head of the national audit of cancer diagnosis in primary care, told Pulse these experiences fitted with other anecdotal reports, but that while he did not agree with referrals being refused or downgraded, it was understandable CCGs were trying to limit referrals in order not to have cancer targets breached.

Professor Rubin said: ‘It’s interesting that this is appearing and that kind of bears out what I had heard anecdotally.’

He continued: ‘I don’t agree with it, but I can understand it. If you are a trust and you loosen the criteria for referral it exposes you to increasing demand, and increasing risk you will not meet the performance targets, with severe consequences.’

He added that GPs should make use of alternative routes to circumvent the referral management systems and that, in his experience, GPs could get patients seen urgently if concerned by speaking to consultants.

Professor Rubin said: ‘Most of the time if GPs talk to a specialist about a patient they are worried about, they get that patient seen. But I don’t think they use that option very often, that’s the problem.’

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Readers' comments (11)

  • In my area I have seen referrals come back with text such as 'this referral has been changed to 'routine'. If you feel that this is inappropriate, please re-refer or discuss'. Note - responsibility 'bounced back' to GP (which is odd given that a detailed letter has already been sent.. funnily enough..urgently) Make of that what you will.....

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  • We had letters from local Trust that they are "struggling to meet 2WW" and to ensure our referrals are appropriate ( well they are) and inform patients to be ready anytime.
    Also very often they are referred to MDT who then reply with a vague answer and and disclaimer " MDT is a advisory body only and the responsilbility lies with the referring physician" - not sure they mean the GP or the consultant team who first saw patient in hospital.
    With new NICE cancer guidelines being even more cautious of symptoms this is likely to to get worse.
    Also the CCG`s are now having to fund cost of several cancer drugs but when CCG`s were set up cancer treatments were to be under the remit of NHSE.
    So CCG`s prescription budgets were ?top sliced for cancer drugs but CCG`s ended up prescribing same from their budget and end up in deficits.
    One couldn`t make this up

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  • Having got NHS Englands Caner Data on our practice for nearly 7 years the above gives no joy.

    201 cases cancer in 7 years, say that isroughly 24 per annum (10% pathway conversion) means 240 referals per annum or 1 each and every working day!

    There is more, told 2WW pathway utilisation is 46% when its actually 66%

    There's more but going for a strong coffee

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  • We are lucky enough to have direct access to CT scanning in my area, but I lack the knowledge in knowing which test to request. Bowel cancer referrals used to just require colonoscopy and was straight forward - not so these days. I do not have time to sit and ponder and once the decision has been made to refer urgently this is what I do.
    For patients who do not necessarily qualify within strict referral guidelines, I will contact the consultant directly at the time of referral so that he/she knows my concerns and act accordingly. I am very lucky in that we have excellent relations with the local consultants and it works both ways.
    From preliminary talks with my CCG, the people who triage our referrals are fellow GPs (not just the 2WR referrals).

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  • Una Coales. Retired NHS GP.

    Working in general practice for the NHS has become very high risk. If a diagnosis of cancer is delayed or missed by the hospital, they may be protected by a collusion of anonymity as often patients may not be able to pinpoint one doctor or clerk who is responsible.

    Instead, it will be easier for the relatives to point blame on the family GP who should have followed up all cancer 2ww referrals and ensured the patient was seen in a timely manner regardless of whether the hospital bounces back referrals.

    An IMG colleague of mine was referred to the GMC by a patient whose cancer diagnosis was delayed...

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  • Took Early Retirement

    Quite so Una, and in most cases the lawyers adopt a scattergun approach anyway, so GP bound to be involved.

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  • And CQC and Daily Wail and our esteemed leader Mr Hunt will point fingers at us for poor practice and how bad we are as GPs. We will get the blame anyway, that is for sure.
    So, the moral of the story is this - if you are already a GP and cannot refer people then it is time to leave, if you are not a GP, please, please do not jump into this fire.

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  • Local hospital management instructed appointments for 2 week wait cancer patients to be accommodated by placing extra slots at the end of consultant morning clinics.
    Combinethat with the fact that 19 out of 20 protocol correct 2 week wait referral do not have cancer and the "consultant experience perception" statements of
    "Stupid GP's make us miss lunch for people who don't have cancer because they are failed clinicians- obviously or they would have been a consultant "was reinforced daily.

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  • Not a problem.
    All re-referrals will carry a footnote stating the original date of the referral, a brief explanation as to why there has been a delay in the cancer diagnosis and a copy sent to the patient or carer.
    Full disclosure in these circumstances will be a safeguard against litigation

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  • This is a perennial worry for GPs: clinically there is a possibility of malignancy, but the patient's symptoms don't tick the box. I applaud NICE's recommendation of a 2ww 'Cancer suspected' clinic, but our local Trust is already wondering how this can be implemented. (2ww referrals up 5-20% locally over past year depending on speciality)

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