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GPs buried under trusts' workload dump

Patients to be allowed to self-refer for cancer diagnostics without going through GP

Patients will be able to self-refer themselves for cancer diagnostics without needing to go through GPs as part of NHS England’s new strategy for tackling cancer, which GP leaders said could ‘undermine GPs’ gatekeeper role’.  

As part of NHS England’s early diagnosis programme announced over the weekend, it will pilot initiatives to offer patients the option to self-refer for diagnostic tests, lower referral thresholds for GPs and introduce multi-disciplinary diagnostic centres where patients can have several tests in the same place on the same day.

It will also set up a taskforce to develop a five-year action plan for cancer services based on the pilots that will include representatives from the RCGP, as well as Macmillan Cancer Support, Public Health England and local councils.

The initiatives will be piloted across more than 60 sites around the country, and they could be implemented from 2016/17, NHS England said.

This comes as NICE published draft guidelines that lowered the risk threshold for which potential cancer symptoms should be referred to diagnostic centres and specialists.

Pulse has already reported that GPs are having urgent cancer referrals bounced back by secondary care, and GP leaders warned that this move could increase the pressure on diagnostics centres, as well as undermining GPs’ role as gatekeeper.

NHS chief executive Simon Stevens said that NHS England’s plans could save 8,000 lives a year.

He said: ‘Cancer survival rates in England are at an all-time high, but too many patients are still being diagnosed late – up to one in four only when they present in A&E.

‘So it’s time for a fresh look at how we can do even better – with more focus on prevention, earlier diagnosis and modern radiotherapy and other services so that over the next five years we can save at least 8,000 more lives a year.

But Dr Kailash Chaand, deputy chair of the BMA and a retired GP in Lancashire, warned that this could undermine GPs’ role as gatekeepers.

He said: ‘There are two issues in this. Fiirstly, who is going to benefit from this? If it benefits patient outcomes, then that is good. But anyone who has a headache for three days might think it is a brain tumour. Overall the whole appointments systems for diagnostics will get messed up. The total outcomes will be limited.

‘Secondly, for the past 10-15 years, the GP role as a gatekeeper has been undermined, with the likes of walk-in centres. This is now going full steam. I won’t be surprised if politicians start saying we don’t need GPs.’

Dr Maureen Baker, chair of the RCGP, said that she welcomed the move, but said the college will look at the proposals to self-refer.

She said: ‘An average GP might see eight new cases of cancer for every 8,000 patient consultations and 75% of referrals made after just one or two GP consultations lead to a positive diagnosis.

‘However, there is always more that can be done and the early diagnosis programme to improve cancer outcomes, is particularly welcome – as is the proposal to create diagnostic centres that could do multiple tests in a single day.

‘We are prepared to look at all the proposals, but in the case of self-referral we would need to understand how it could work effectively without diverting resources from other services.’

Related images

  • ultrasound scan cancer diagnostics PPL

Readers' comments (52)

  • How long before the system collapses?can secondary care cope with a flood of worried well?can we afford it.Once diagnosed how long for a op with no slack in the system.Before the idiots bring up an idea like this they should see if its doable in the first place.My money is on a complete mess like the cancer drugs fund.

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  • People are already saying we don't need GPs.

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  • Giving GP's access to MRI /CT is the obvious solution . Open access to all will be an expensive mistake limiting use for those who actually need it .

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  • Await the flood from Dr Google

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  • What a bunch of F~#kwits . All medical investigations carry a risk - especially those involving radiation . CT is an X-ray density map . Do enough and these might induce cancer in falsely reassured people . Targeted investigation is better all round. Can I suggest mantle irradiation of 2000 rads for berks that thought this one up

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  • The current NHS system cannot cope with this demand and this will be the ideal opportunity for private screening companies to come in and offer these tests to all and sundry. Privatisation of services which will have to be open to tender, removal of these pesky, difficult GPs who get in the way of patients having all these lovely tests and collapse of the NHS hospitals who will have to actually manage and further investigate these patients who may be falsely negative plus as an added bonus the failure of all CCGs budgets paying for all these excessive tests and investigations. Sounds like a brilliant strategy to make the entire NHS system fail to me....

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  • Fechiniijits

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  • Very good if it helps speed cancer diagnosis but it is yet another tier and might just be another sticking plaster on a flawed system. It will also require additional funding to prevent delays and withdrawal of other services? However at present patients often fall in between the precise referral criteria yet GP clinical judgment dictates that cancer needs to be urgently excluded. These patients still frequently turn out to have cancer but often face severe difficulties and delays negotiating the system especially in areas that have referral (mis)management. The GP will still need to be involved and somehow get them investigated and fight against their urgent cancer referrals that are bounced back by referral management and secondary care.

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  • It's not as if every patient with a headache thinks they have a brain tumour or those with a cough think they have lung cancer or anyone with a rash or an itch thinks they have skin cancer. I'm sure the system will cope!!!!!

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  • Well at least it may permit some of our consultant colleagues to move their personal thinking on from:-
    "stupid GP's refer too many people who don't have cancer"
    to
    " there are a large number of people very worried and presenting symptoms suggestive of, but who do not have cancer."
    The only absolute in my book is that the direct access service must manage the repeated attendances for rechecking and not deflect them onto the GP, given the published body of evidence that
    "reassurance investigation"
    increases frequency of future presentation.

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  • No it's probably just 10 % - cope with that ! HA HA HA .

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  • Peter Swinyard

    No, in my personal capacity as a GP, I do not support this initiative. It is at best well-meaning but muddle-headed.
    One of the basic tenets of making a diagnosis is to start with the history and no computer algorithm, or NHS111, or Dr Google, is as good as a GP listening to the patient, asking the right questions and formulating a management plan. As a previous respondent said, investigations themselves carry a risk - which is why X-rays must legally be signed off by a practicing doctor.
    The positive return on investigations requested by GPs is already much higher than those requested by hospital junior doctors - we all worked there once but have added years of experience and training since.
    This is populist nonsense in an election year. I am not being protectionist over our craft - but I am being protectionist over our patients' welfare and our NHS resources.

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  • why are people fretting about being 'needed'.

    Do you think anyone at NHSE has done a cost benefit analysis on this? do you think they know how to open a spreadsheet?

    Its uncosted and based on unproven associations with 'increased cancer diagnosis rates ' in some parts of Europe.

    As usual NHSE is full of zombies with single digit IQ's - what do you expect?
    Can you imagine the number of incidentalomas that will be picked up and have to have some sort of treatment!

    I suspect we'll be even busier then ever(unfortunately).

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  • Clearly idiotic, but a logical step when patients already have a right to further referral and investigation under the NHS constitution. More annoying is the frequency with which it takes us 3-4 referrals into secondary care to get a specialist to take vague symptoms seriously, and investigate sufficiently to find the cancer we suspected due to professional experience & gut feeling, but couldn't irrefutably find on a diagnostic test.
    The resourcing of this will be near impossible.

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  • To Dr.Chaand,
    I will be very glad if that happens. We are trained to be doctors, not advocates and gatekeepers. We need to move on from this old ideology
    In any case, I do not count myself as a gate keeper.

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  • I think investigation facilities should be made available to all patients who are worried about cancer and should be able to self refer for cancer investigations - but such patients should be charged for these investigations.

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  • The guidelines on GP direct access are a welcome addition - at least there is some sense.

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  • send everyone for everything- or go to court to defend your criminal negligence; stable is on fire, doors have been removed, why are you trying to keep the horses inside?

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  • Absolute tosh!

    My partner is a specialist nurse and runs triage for cancer referral in her speciality - I hear almost daily moaning of GPs referring Pt who really should not be referred. Anything from one episode of rectal bleed with no other symptoms (yes, they can be referred under normal pathways but shouldn't be under 2ww) to someone who already had investigation just 6/12 ago with no change in symptoms (and no mention of having these done in the referral, suggestive of improper considerations).

    Many of us are very good but some of us are not. And the public will be even less medically trained then not so good GP......

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  • I am imagining a process whereby 2ww referral forms are available for the general public - and if they can tick one of the boxes, then can then go for the special cancer tests.

    If it is done properly (agree that is unlikely with NHSE) it might actually help. It will stop 15 year olds insisting that they need cancer referrals for their 4 days of diarrhoea and might stop cases where the press blamed the GP for not referring early in unusual cases. (Like Stephen Sutton)

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  • Either there is good evidence that a substantial number of cancers are being diagnosed late because of unnecessary delays by GPs (in which case please produce it) or this is non-evidence based and politically driven and those involved are quite happy with the implication that GPs are to blame (in which case stop reading Mr Thomas and the Daily Wail). Alternatively, like the Labour Gvt in 2004, those making the decisions have absolutely no idea how much we do.

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  • this is welcome news as ;

    - if simon says it's a good idea then it is.
    - it empowers patients and all patients have legitimate needs and all are vulnerable and all patients will use this resource sensibly. we should stop being cynical and trust our patients.
    - if patients have enough CT scans (e.g. repeated weekly) - then I'm sure they will find a cancer.

    The problem is not politics, poorly thought out ideas, NHSE, CQC, bureaucracy, low morale, retention or recruitment, demand outstripping supply etc. it's cynical GPs - try and be more positive !

    now where are my antidepressants.

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  • @1258 or if they have enough ct scans they'll get cancer because of that ;)

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  • I agree with this. it will stop a lot of time waster coming to GP's and they can get what they want by wasting someone else time and I can see patients who want medical care and value my advice. Everyone is happy, no complaints. I too have to agree that the gatekeeper role is not what I am here to do. I will not deny patients access to specialists if it is even vaguely clinically indicated or if they are not happy with the advice I give them. If they want a referral because they are worried and want to see a specialist by all mean. Until the NHS constitution takes that right away from them.

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  • F*ckwits they might be, but if it takes work away from GPs, and costs of followup tests and appointments, and time for chasing up crap, by all means. let someone else deal with the worried well. Anything to lower our workload.

    My worry here is that looking at the RCGP and GPC response, if this system is put into place, we will have to deal with some of the additional 'fallout' e.g. chase results, follow up appointments, etc. If you want to take it out of the GP's hands, then you better have the resources and manpower to deal with everything after, cos I sure as hell ain't going to be asked to do anything after, if I ever thought a patient did not need to be seen/investigated.

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  • Vinci Ho

    In a way , this is the mentality of 'patients are exactly the same as customers' as long as you can make it fast and convenient to please them.But customers know what they want when they walk into the shop but patients ? Do they know exactly what they walk into ?
    Of course , we were told to copy Tesco, so let's have a Tesco style of diagnosing cancers!
    By the way, I suppose people realise what has happened to Tesco these days?

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  • Aren't we constantly told to involve the patient in decision making over referrals, investigations and treatments, rather than being paternalistic?
    Then NHSE are only taking this advice to the logical conclusion. Better think about re-training.
    Patients with enough money or insurance already can get what they want, levels the playing field for all. Just off to get an MRI for my TATT.

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  • Bring it on. Perhaps they will then learn we are of value in deciding who to refer and when.

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  • Is it April 1st? This is a joke right?

    Well, when Gibbons writes "Decline and fall of the NHS", we'll know what the final nail was.

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  • The Tories have been driving nails in daily,and to their dismay the NHS just wont die.Hopefully it will bite them come election time.

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  • So when patients fail to make a diagnosis they can sue themselves .

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  • Is there anything Maureen Baker does not welcome ? How little do we respect our profession and amazing how the people representing us have no backbone and seem to agree with any initiative that comes our way...however nonsensical it may be

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  • Why are General Practice & A & E in a state of crisis? Because patients can access them directly free at the point of use without any consideration of the costs involved. Now the DoH wants to do the same to Oncology while NHS finances are stretched to the limit. Think again Mr Stevens.

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  • Have they never heard of VOMIT?

    Victims Of Medical Imaging Technology

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1126156/

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  • I'm coming to the conclusion the underlying agenda is that General Practice is of 'no value' and 'needs to be disbanded' along the lines of the myopic lunacy of folk like Prof M Thomas.

    You get this theme in so may story's published in this magazine these days. I read the other other day that the guy in charge of NHS Englnd recons physical GP appointments will be 'a thing of the past' in 'New Towns' with everyone simply using a smart phone app.

    To be honest, I say, let them have what they wish for. I hope these numbskulls rot. I know enough about the human condition and illness having been a GP for a decade to know you can't replace a Dr with a Google account and access to Skype. Plenty of folk (mostly those who haven't ever had the misfortune of being chronically ill) are under the delusion that you can.

    So be it. The evil part of me will enjoy watching them chase their own tail down the rabbit hole.

    I won't have a job doing what I'm doing now but I'll be able to have a laugh all the same.

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  • When you check the number of imaging companies that donated to Tories in run up to last election......can't help but be a tad cynical.

    Perhaps Macmillan will be putting in a bid for this as well (as Staffs). I can just see the Macmillan staff in the triaging cubicle at the back of Walgreens Boots Alliance (that's Boots to you and me) - after all, greasing palms is nothing new for Boots' new partner - $7.3m to political campaigns in last 15 years in USA.

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  • One word
    Daft

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  • "That’s the standard technique of privatization: defund, make sure things don’t work, people get angry, you hand it over to private capital."
    Noam Chomsky,
    There is no hope for the NHS..
    47 year old Dedicated GP partner currently off with burnout

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  • in these days of over burdned gap's,let them get on with it.you can only take the political mules to the water .....

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  • Anonymous | GP Partner | 12 January 2015 11:20pm.

    well said.one of the few people who know Noam Chomsky and probably Norman Finkelstein as well

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  • Does the Oncology Dept really want queues of worried well at their door, meaning it takes months instead of 2 weeks to get an appointment? If the hospitals don't realise how much dross general practice protects them from then maybe they do need to learn the lesson the hard way.

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  • Hang on... according to the Govt, A&E is overloaded because people go straight to hospital instead of their GP. So it proposes that people should go straight to Oncology instead of their GP, and the logical result of that will be....... Oncology will be overloaded.

    I thought that having an IQ in negative numbers was mathematically impossible, until along came NHS England.

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  • At 9.06

    This could be a patient safety issue. The two week wait could be at risk by overloading the system.

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  • Perhaps I am over-sensitive but this furtther dismissal of GPs as irrelevant at best and obstructive at worst seems to demonstrate the mind-set of NHSE/DoH/whoever came up with this "bright" idea.

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  • Anonymous | GP Partner | 12 January 2015 6:26pm

    Is there anything Maureen Baker does not welcome ? ...

    yes

    1) any talk at looking at alternative models and allowing all GPs a vote on OUR future.

    2) making a fairer exam process.

    3) any moves to help retention and recruitment

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  • As ever there is more behind this than picked up in a press release:
    All projects included came from existing local projects. They are being included in a national evaluation so effective initiatives can be adopted at scale and pace.

    Of the 60 projects only one is about self referral - for chest x-ray (targeted at at risk populations). The vast majority of projects relate providing GPs with direct access to diagnostic tests or putting in place symptomatic pathways/new services for patients with vague symptoms.

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  • so 5:11
    the truth at last? this sounds more plausabe and sensible.
    Pulse being as inflammatory and imaginative with the truth as the Daily Fail on this one.
    The prospect of people just being able to rock up for an MRI of whatever is ridiculous beyond belief.

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  • In some conditions, especially where there are potential delays in presentation and referral associated with poor local outcomes, this can be successful. In Leeds there has been a scheme allowing patients to present for an open access chest xray if they are over 50 and had a cough for 3 weeks or more. As a result of this there was an increase in the number of patients attending for xrays and an association with patients presenting with cancer at a lower stage after the scheme was implemented. I think it is unlikely to be relevant to all cancer types but, if properly targeted and based on local issues with cancer diagnosis and outcomes, then there may be some merit in allowing patients direct access to some diagnostic and assessment services.

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  • Both James Perry and Simon Julme are missing the point. Even if it was 'just' a chest x-ray, it is an investigation involving radiation, and has a cost to it, and with any other investigation, should have a clinical indication for it. the risks/benefits of any investigation are best balanced by an experienced clinician, be it a GP or a specialist, not a patient.

    Even if somone over 50 had a cough for more than 3 weeks, but if they had a CXR 2 months ago which was normal, would you let them do a CXR again?

    And where would you stop? first its CXR, next its MRI, CT, cancer bloods, etc..... You might achieve earlier diagnosis in some cases but would a better route to that not be all ther other suggestions e.g. GP access to diagnostics, more GPs, public education

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  • I already have patients coming to see me 7 days after having hospital tests (ordered by consultant colleagues) and saying, "But the radiographer/ ultrasonographer said my doctor would have my result by now! I don't have an appointment with the hospital for another month and I want to know if they found a cancer NOW!" Patients may well have the scans, but who's going to be left with the responsibility of chasing them up, I wonder. Unfortunately, I really don't see this reducing workload at all. Apart from what everyone else has mentioned regarding resources, risks of over-investigations etc.

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