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Straight to detest

Copperfield 

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 http://www.pulsetoday.co.uk/views/copperfield or follow him on Twitter @doccopperfield

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Readers' comments (14)

  • Not entirely convinced it helps even when they see a clinician. As long as "cancer excluded" regardless of whether the initial symptoms have been addressed people get discharged. Wish I could get away with saying as long as it is not one condition no point doing anything else!

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  • I referred a 65 year old lady with epigastric pain anorexia and weight loss and she had the STT response of a normal gastroscopy and discharge. a week later she went yellow and saw a colleague who sent her back and now she blames me for missing her pancreatic tumour. This is exactly the result predicted by the honourable copperfield.

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  • 2ww was another tiresome scam that GPs stupidly accepted as an improvement. In reality it transferred all the risk of triage and diagnosis to us in an unmitigated fashion. This lead to all sorts of potential for legal profit when attacking GPs over 'missed cancer.' The same thing happened with sepsis and we fall for it every time.

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  • Yes totally true - am getting totally fed up with specialists not following up on their results also..

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  • Spot on. Had a case STT. Seen a colonoscopy nurse who could not get past the sigmoid and sent back to GP. Should I consider a scope completed? It turned out the stricture was the cancer after I re-referred the patient.
    What happened to informed consent, counselling before a procedure and sorting all the differentials and managing it like a consultant should? But then you get Noctors and STT. Straight to trouble.

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  • Any gastroenterologists out there want to explain this new type of Dumping Syndrome to us?

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  • Too many patients. Not enough specialists. Reduced funding.

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  • I guess it depends. I have no problem with straight to testing as long as the patient is followed up whether the test is positive or negative, by a responsible clinician. The stories above are obviously wrong but no point seeing a consultant for 5 mins who says “well have a scope and see me after”

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  • @Whoaml
    Agree that they don't necessarily need seen before- but I think they should all be seen after to give patients a chance to ask questions and formulate sort of diagnosis/plan. and not when they are coming round from the midazolam or the stresses of the procedure.

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  • 4) clearly if it isn;t cancer then the hospital doesn't give a big watery stool!

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