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GPs told suspected bowel cancer patients required positive FIT before referral

Exclusive GPs in London were blocked from referring patients with urgent suspected bowel cancer to hospitals based on symptoms alone under changes to local NHS guidance due to the coronavirus pandemic.

NHS England’s London team said at the start of May that the two-week wait referral threshold for lower gastrointestinal cancer had been raised and that patients could only be referred if they had a positive FIT test result.

But GP cancer experts warned a negative FIT test result does not rule out cancer altogether.

The change went against NICE guidance, which allows GPs to refer patients based on just their symptoms, such as a change in bowel habit.

However, NHS England’s London team said it has written to GPs stating they may refer patients if there is ‘strong clinical suspicion’ , but that a FIT test must still be carried out to aid diagnosis.

Meanwhile, one London NHS hospital trust contacted up to 749 referred patients mistakenly telling them to pick up a FIT test in person from their GP practice – when it should have been sent in the post.

The referral pathway was changed after the British Society of Gastroenterology recommended all non-emergency endoscopy procedures be halted, alongside a six-week suspension for urgent suspected cancer referrals due to the risk of Covid-19 transmission.

In April the BSG said: ‘We suggest an immediate pause of six weeks for symptomatic referrals including two-week wait / urgent suspected cancer referrals and case-by-case triage.’

In response, NHS England’s London clinical advisory group agreed the FIT tool should be used to triage suspected colorectal cancer patients before referral to hospitals.

An email, seen by Pulse, that was sent by Epsom and St Heliers University Hospitals NHS Trust to its local London practices on 6 May said: ‘Due to the Covid-19 pandemic, the referral pathway for lower GI TWR [two-week rule] referrals has changed. The following mandatory pathways have been agreed by NHS England (NHSE) London clinical advisory group.

‘All high and low risk patients as defined by NHSE guidelines now need to have a FIT test first except where a patient presents with a rectal or anal mass where these patients should be referred on a TWR pathway as normal.’

It added: ‘From 11 May 2020 onwards referrals without a positive FIT test will not be accepted and should be treated locally by the GP for four weeks.’

The email went on to add patients with a negative FIT result should be ‘safety netted’ by practices.

GP Professor Willie Hamilton said the approach is being used in other regions too and warned while the FIT test may be a ‘sensible’ way to triage referrals, it does not pick up on all cancer cases.

He told Pulse: ‘It’s not just London, but much more widespread. As hospitals are doing almost no endoscopies/colonoscopies, and as CT is very restricted, they are looking at ways to triage their two-week wait referrals.

‘It’s sensible enough – if you have very limited endoscopies you should use them on those most in need. The FIT negatives are unlikely to have cancer, but you can’t rule it out definitely.’

Dr Abhijit Singh Gill, a GP based in west London with a specialist interest in oncology, added: ‘Having a negative FIT test means there is a high likelihood we are not dealing with cancer but with it being mandated there are some risks - early stage polyps or adenomas could be missed.’

‘A negative FIT test for symptomatic patients means there is a 0.4% chance that there is still a cancer there that has been missed. Separately there is also the issue of adenomas, which we wouldn’t know about from the test.’

He also noted the onus had been put on GPs to manage the patients: ‘The advice for GPs to keep an eye on patients with a negative result for four weeks is a shifting of responsibility on to GPs, which raises the question of safety netting and how we do this.’

But in response, a spokesperson for the NHS in London said: ‘We have recently written again to GPs regarding the changes that have been made to prioritise the safety of patients and staff, reiterating that they can continue to refer patients if there is strong clinical suspicion.’

The spokesperson clarified to Pulse that GPs would still be expected to carry out a FIT test under the new policy.

Following the decision to switch to FIT tests in the capital, in east London, Barts Health NHS Trust sent a letter on 23 April to up to 749 patients referred to its Royal London Hospital site, informing them they would need to pick up a test kit from their GP practice.

But on 14 May local commissioners wrote to GP practices telling them the letter had been sent in error and that these patients would instead be sent a FIT test kit in the post – which only once completed should be handed in to their practice.

A spokesperson for NHS Newham, NHS Tower Hamlets and NHS Waltham Forest CCGs said it was not known how many patients had acted on the letter and visited their GP practice unnecessarily.

The spokesperson said: ‘As soon as we became aware of this issue, a new letter was immediately sent to the patients involved and GP practices were informed so they were aware of the situation and clear on the locally-agreed plan.

‘We have worked together with colleagues at Barts Health to ensure patients who need a FIT test receive one as quickly and safely as possible, and that their results will be actioned appropriately.’

Readers' comments (10)

  • I'm more worried about the people I referred with a positive FIT test, who have been telephone triaged and told they don't need urgent investigation because their test is only 'mildly positive'. Is the threshold suddenly different?

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  • London is subject to Hospital Take over primary care.

    Changes like this, are just the beginning of the shift of activity.

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  • This is wrong - West Mids Cancer network has suggested using FIT to risk assess urgency for investigation and even then not in all circumstances not a blanket change.

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  • Dangerous and unethical. The pen pushers interfering with clinicians again.

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  • Our local lab has stood down FIT testing during the pandemic!

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  • Who is 'NHS England’s London team' - who send inert, nameless documents and threats? - why are they anonymous, hiding and not bashed and slaughtered like the front-line? Let's see a patient with a cough together shall we? Let's audit it in fact.

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  • and the practices that have no partners and just run by locums - yep thats gonna work - and the patients who can't do fit tests? are they to be rejected because of disability? are they going to pay for the extra workload to review after 4 weeks by the GP and take responsibilty when a cancer is missed by 4 weeks with a normal fit test?

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  • Just Your Average Joe

    Hospital who took referral should post out the FIT test if they want it done, and take responsibility for the test and result.

    No where does the GMC require you to jump through hoops to refer.

    The NHS Charter allows patients who require a specialist opinion to be referred as their right to this option if they wish.

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  • This is a rapidly changing area, and NICE guidance looks increasingly out of date.
    With a negative FIT test the patient may have cancer, and may even have CRC but is much more likely to have a cancer that isn’t CRC.
    A 2WW to colorectal with negative FIT is likely to delay diagnoses.
    Usually the best investigation for what are often nonspecific symptoms is to go straight to CT, but this often isn’t available.

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