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Will test access ease GPs' angst over Ca referral?

The cancer tsar is backing a plan to allow GPs direct access to diagnostic tests ­ Emma Wilkinson reports

It is a frequent but frustrating dilemma. A patient comes in with symptoms that could be cancer, but probably won't be.

Should you refer the patient straight to a specialist under the two-week rule or is it safe to wait months for a standard appointment?

Faced with such a quandary, many GPs feel compelled to err on the side of caution ­ leaving secondary care services dangerously overloaded and policymakers scrambling for a solution.

One proposal to ease pressure on hospitals is to allow GPs direct access to diagnostic tests, with more of the patients needing urgent attention.

GPs would be able to send patients directly for colonoscopy, CT, gastroscopy, endoscopy, ultrasound and even transrectal ultrasound scans.

The strategy has the backing of the Government's cancer tsar, Professor Mike Richards, who told Pulse: 'If a GP has ready access to tests they might not have to refer and the patient can be reassured.'

Various types of schemes are already up and running. Last week, Pulse reported on a Leicester-based straight-to-test pilot for patients with suspected colorectal cancer, which dramatically improved time to diagnosis.

Project leader Mr Michael Kelly, who is also national clinical lead for colorectal cancer, said national uptake of 'straight to test' would lead to a 'widespread reduction' in waiting times for all patients.

But he does not believe GPs should have a choice of tests.

Instead, patients in the pilot were allocated colonoscopy, sigmoidoscopy or barium enema by hospital staff upon referral.

Dr Roland Valori, consultant in gastroenterology at Gloucestershire Royal Hospital, agreed some consultants were sceptical about GP involvement in ordering tests.

'Our surgeons have devised direct-access pathways for two-week waits but because GPs refer many patients who do not fit the criteria they prefer to see most in clinic first.'

Dr David Baldwin, consultant in respiratory medicine at Nottingham City Hospital, said his hospital had a system for arranging CT scans prior to clinic appointments.

But he warned if GPs had access to CT directly the system would not speed up by 'more than a day or so' because more investigations would be ordered.

Yet in the era of practice-based commissioning, it is inevitable GPs will gain more control of diagnostic services.

A pioneering scheme by Leicestershire, Northamptonshire and Rutland strategic health authority will give GPs direct access to any investigation within 28 days by December 2007.

Dr Orest Mulka, cancer lead for Charnwood and North West Leicestershire PCT and a GP in Measham, Derbyshire, said it would 'revolutionise' cancer diagnosis.

'We won't need to refer under the two-week wait. There will be fewer patients waiting to see specialists and it fits in really well with practice-based commissioning. It will make a huge difference to GPs and patients.'

Dr Charles Buckley, cancer lead for Cotswold and Vale PCT and a GP in Frampton-on-Severn in Gloucestershire, is equally keen GPs should have a greater gatekeeper role.

He said: 'The NICE guidance picks up people even with a vague suspicion of cancer. The number of referrals under the two-week rule has almost doubled and the service is overloaded. The system needs to be more flexible. GPs would be very happy to start the ball rolling.'

Dr Murray Freeman, cancer lead for Birkenhead and Wallasey PCT, said: 'We've been looking at rapid access ultrasound. We don't have it so it becomes a two-week wait referral immediately.'

Dr Freeman, a GP in Birkenhead, added: 'Anything that improves pick-up rate and stops us referring things we know won't be cancer is a good thing.'

Anything, in fact, that releases GPs from their dilemma over cancer referral.


Options to extend Ca test access

Straight to test

GPs refer under two-week wait but patients sent straight to testing before hospital appointment.

Mr Michael Kelly, national clinical lead for colorectal cancer, said: 'GPs are not in the position to choose the test. With colorectal cancer there's a huge number of people who could potentially be tested.'

Direct access

GPs send patients for specific tests and refer to specialists on basis of results.

Dr David Wild, cancer lead for Calderdale PCT, said: 'I feel we should move towards rapid access to diagnostics to all patients. That in my opinion is the best chance of reaching acceptable pick-up rates.'

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