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Independents' Day

Straight to detest


I hate a lot of things, but what I currently hate most is ‘Straight To Test’. Or, if you must, ‘STT’. Assuming this initiative isn’t just another punishment inflicted on Essex for being Essex, then you’re suffering it, too. If not, you soon will.

STT does what it says on the tin. You refer patients on the two-week pathway and, instead of having a consultation, relevant tests and a follow up letter/appointment, they receive a phone-call (from a nurse specialist, obviously), the relevant tests and then, unless there’s a barn-door abnormality, they’re bounced straight back to the GP.

Typically, this ‘efficient and seamless pathway to optimise the patient journey’ (not an actual quote, I made it up, but it’s what they’d say, isn’t it?) was imposed without any consultation with grassroots GPs. Had they asked me, I’d have been able to tell them, prospectively rather than retrospectively, that it’s a horrible idea. And here’s why:

1. It means that, when I tell a patient I’m referring them to a specialist, I don’t really know if I am or not. They might encounter a real specialist. Or they might just meet the pointy end of a colonoscope.

2. It’s psychologically traumatic for patients to be referred under the two-week rule, not least because we’re obliged to tell them it’s a check for cancer, it’s an urgent appointment and it’s important to attend. In writing. If the system was humane, it would incorporate at least some face-to-face contact with the specialist team. It isn’t, so it doesn’t.

3. This is simply another way of the hospital keeping patients at arm’s length, diluting their responsibility while increasing the GP’s.

4. Most importantly, STT significantly expands the GP role. I don’t refer patients just to rule out cancer, I refer to rule in other significant and treatable disease. If my patient’s unexplained diarrhoea isn’t the Big C, then what is it?

Not everything that isn’t colon cancer is IBS. So am I confident that I can exclude (from the STT results +/- anything else I can arrange myself), say, colitis, malabsorption, coeliac, intolerance, mesenteric ischaemia, etc etc?

Suddenly, I’m doing the job of secondary care gastroenterology – and if not, then I’m making a second, routine, referral, entailing more work for me, more expense for the NHS and more hassle and anxiety for the patient.

On paper it probably looked like a good idea. But for me, it’s Straight To Detest.

Dr Tony Copperfield is a GP in Essex. Read more of Copperfield’s blogs at or follow him on Twitter @doccopperfield

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Readers' comments (15)

  • I agree with all contributors.

    For the GI cases which will get scopes first on a 2WW basis and no clear pointers on the bloods IDGAFs thus far successful policy is to write/type on the form "needs scope(s) and if NAD, CT".

    Successful here means blame deflected by thinking a step ahead. I have had more than one apology letter from a consultant when their premature dismissal of a case has resulted in cancer being missed. IDGAF has also found increased traction with subsequent referrals.And probably some unexpressed hatred.

    Its all a fu##king game folks.

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  • Try managing the job of a hospital specialist, once the STT has excluded a barn door cancer, when your access to additional tests and imaging is limited and/or scrutinised by the “clinical forum” of your CCG. I well remember a row about whether MSU was a standard GP test when investigating urinary symptoms, and while we were being “encouraged to reflect” via the usual normal distribution curve exercise, pointing out that the Urology department was sending flat rejections to patients without an MSU in the past 3/12. They beat you up for missing diagnoses, deny you the tools to do the job of an F2, and with STT you get the non-cancer 90% of Kumar and Clark to look after. An impossible job I am well out of.

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  • A lot of sensible input. However, god help those that help themselves. A plumber would not allow you to watch what he does for obvious reasons. We as a profession need to look after ourselves and stop giving managers and others reasons to come into our line of work. Even a plumber knows that.
    Want to do a doctor's work, go into medicine. We have a duty to the profession and to our juniors. I was leaning about varicose veins surgery and doing them well as a medical student. These days, even a consultant gets deskilled from prior approvals. There is a cost to the profession, the patient and the consultant in deskilling that the government and managers are not counting.

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  • Referred pt with iron deficiency anaemia and dyspepsia on Upper GI 2WW as per guidelines. Noctor scoped upper GI and discharged to GP - apparently didn't do lower GI Investigation as on wrong pathway! Had to re-refer and fortunately patient didn't have sinister cause.

    Although sometimes things work! Risk averse colleague referred 35 yr old with loose stool and raised faecal calprotectin to lower GI 2WW - no blood or anaemia. Scope showed colitis and now has Gastro clinic follow up booked. Patient has no idea why though as no one spoke to her about her likely Crohn's disease!

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  • Generally "worst diagnosis ruled out" has become the fsctory setting for a lot of secondary care encounters nowadays. Our consultants are smart and experienced clinicians with excellent communication skills. We see their full prowess when they have the opportunity to see patients properly in a private consultation. The NHS seems to settle for diagnosis avoidance: "medically fit for discharge" for example doesn't seem to be in any textbooks although this is often the only thing a patient can recall about the outcome of their admission. I do not have a CCST for their speciality so I usually send them back to clinic...

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