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The waiting game

GPs told to inform patients of suspected cancer... or hospital administrators will do it for them

A hospital has told GPs its administrators may inform patients that they have suspected cancer unless GPs are explicit to patients when using the two-week urgent referral pathway.

Local GP leaders said that John Radcliffe Hospital in Oxford is introducing the ‘blunt’ strategy because GPs are not conveying the urgency of the referrals, meaning patients are refusing the appointments on ‘trivial’ grounds, such as going on holiday.

Berkshire, Buckinghamshire and Oxfordshire LMCs’ chief executive Dr Paul Roblin said that he could see ‘both sides’ of the argument, and that the hospital was acting to ensure patients didn’t delay further investigations.

However, he added the news needed to be broken sensitively, particularly because the staff arranging appointments were unlikely to be ‘clinically proficient or have the clinical skills to deliver the news in the right way’.

The LMC has written to practices outlining that, when making a two-week wait referral, they should also make clear their first appointment will need to happen within two weeks, and could be at the first available hospital, so their plans might need to be altered.

Dr Roblin said: ‘If a patient isn’t aware, that a pretty blunt and potentially distressing way for patients to find out.

‘So I’ve encouraged practices to be clear with their patients that two-week wait means cancer is a possibility. And the GP can develop that to deal with each patient as an individual.’

He said it is ‘variable’ whether GPs do it at present, and that is the reason the hospital has taken that stand.

Dr Roblin said: ‘When the hospital has phoned up with an appointment in two weeks, patients often say “well I can’t make that”, and the hospital has to say “you are being referred for the exclusion of cancer, do you realise that?”

‘So I do sympathise with both sides, GPs need to play their part in informing patients, but the John Radcliffe has to deal with patients in a sensitive way. Especially if it’s administrative staff offering the appointments, they’re not clinically proficient and they have to have the clinical skills to deliver that news in the right way.’

Urgent GP referrals for cancer have increased 50% in the last five years, largely because of awareness campaigns and drives to boost GP referring. But the two week wait target could soon be scrapped, as a Government cancer target has suggested replacing it with a four week target for diagnosis.

Oxford University Hospitals were approached for comment but had not replied at time of publication

Readers' comments (18)

  • My consultant friends say that only 10-20% of the patients they see via 2ww referrals have cancer. So 80-90% will be given false anxiety of the first order.

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  • as GPs we should be informing patients what the 2ww pathway is for - suspected cancer. Doesn't mean we think they have it, but that it could be a possibility.

    If you don't use the words, somebody else will. Much better to come from the GP than the random registrar they see "so you've come because of bowel cancer" etc etc

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  • "Suspected cancer" is not a diagnosis. [Trundles back to Pedants' Corner with the memory of the patient who used her label of "suspected gallstones" as a pretext for jumping the appointments queue long after the scans had shown a gleaming hepatobiliary system.]

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  • Informing a patient of a 'suspected' or confirmed cancer is not that simple. Breaking bad news is an art one masters throughout one's career and still it goes wrong. How does a hospital still functioning Doc Martin style expect to survive and is it planning to train it's administrators in advising patient's of 'suspected cancer'? What if a patient commits suicide and it turns out it wasn't a cancer at all? Manslaughter or homicide? Or would the Hospital declare 'Lessons have been learned'

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  • I second what Lorna says. Suspected cancer is not a diagnosis. I have many patients on whom I do a number of tests to rule out various conditions, including cancer. I only mention cancer during this process if I judge that the benefits of doing so outweigh the disadvantages.

    For 2ww referrals, I will mention it if I think cancer is likely. If I don't, there is no benefit to mentioning it.

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  • Mrs Smith, I am referring you on what is known as the two week wait pathway, introduced by those who organise these things to improve early diagnosis rates of cancer. Your symptoms match the symptoms I am told to refer using this tool and so, ever anxious to keep my job in these litigious times, I am doing what I am told I should. For the record, I don't think you do have cancer, I think you have piles. But I have seen too many of my colleagues face the agonies of being sued and referred to the GMC for not following what we once called guidance, and yes, seen too many patients packed off with anusol only to return 6 months later with metastasis. So, all things considered, you're off for a camera in a fortnight. Now, yes, it's true you might have cancer. But then you might be hit by a bus on your way home and neither you or I will lie awake tonight weighing the pros and cons of your transport options home. I am afraid I am practicing defensively, which isn't to say I'll slide tackle you like John Terry in the corridor. Rather that my brain, for all its 25 years of practice, is now considered redundant. You have bleed from bum. Ug. I refer on special form. Ug. I keep job. Ug. Is this robotic, risk free, gatekeeperless, scans for everyone system wonderful. Almost utopia, no? So, are we clear then? Your 10 minutes is almost over and I still have to type up my bulletproof notes. Questions? No. Very good. Bye then. And remember, if it gets worse, pop along to A&E and tell them you're a haemophiliac, just for fun. They could do with the work. See ya.

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  • I should add that I *do* use the word "cancer" when explaining the two week wait system to patients.

    Sometimes it's appropriate to warn them that there's a real possibility that their symptoms will turn out to be due to a specific cancer. For most patients, this doesn't come as a shock - if someone has already worked out that they might have cancer, it helps them to know that their GP is taking their concerns seriously.

    More often, though, it's to explain that I'm using a referral system designed for people whose symptoms *might* be due to cancer, but that there are much more common causes of those symptoms, the vast majority of people with these symptoms turn out to have something that's treatable or trivial, and that the patient should not be alarmed that I'm using the suspected cancer referral pathway.

    I respect other GPs' preference to avoid mentioning cancer at the referral stage, and would like to think that my colleagues in secondary care wouldn't sanction a staff member who has not been appropriately trained to throw the C-word at patients.

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  • Now that NICE has lowered its threshold to 3%, this really dose pose a significant risk to patients. "Suspected cancer" sounds to a layman "I think you do have cancer" whereas 3% means "you might have cancer, but probably not!"

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  • At the 2.31 partner...the "ug" bit
    I still have the article written by Copperfield which i read in my GP reg year c.2001 in which he said most of his daily clinical decision making was at the spinal level which a retarded monkey could do.
    Depressed the hell out of me back then.
    Thank f*uck i got out of general practice

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  • Russell Thorpe

    We should definitely tell people that they are being referred for urgent investigations to exclude a cancer. We should also tell them The probability is that it isnt but dont rearrange your appointment as its very hard for the hospital to see you within 2 weeks. Id say 90% of the time its what the patient is woried about anyway.
    Re working at a spinal level it is precisly because we were so bad at timely referral for cancer that the 2WW was introduced. If you review the case notes of patients with late diagnoses, as I have done, it is at times horrific, appalling and indefensible.

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