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GPs need to ‘shift mindset’ to ‘lower threshold’ for cancer referral, says RCGP chair

GPs need to ‘shift mindset’ to ‘lower threshold’ for cancer referral, says RCGP chair

GPs need to ‘shift mindset’ to where ‘our threshold for referral’ for potential cancer ‘is lower’, RCGP chair Professor Martin Marshall has told MPs

Professor Marshall was giving evidence to a House of Commons health and social care committee inquiry investigating the NHS backlog’s impact on mental health, general practice and long Covid care when he made the comments.

Committee chair Jeremy Hunt had asked ‘how open the college would be’ to ‘moving to a system’ similar to the one in France, ‘where people have direct access to specialists and cancer diagnostic tests without having to go through their GP as a gatekeeper’.

In response, Professor Marshall said that in the past GPs were trained to ‘pick up the red flags, the important symptoms, and refer those on’ but not ‘refer the many people who have symptoms that could be cancer but where it’s highly unlikely, because the NHS would collapse if that’s what we did’.

But now, GPs need to ‘shift that mindset’ to where their ‘threshold for referral is lower’. 

Professor Marshall said he is ‘fully in favour’ of proposed community diagnostic hubs, as ‘we have to have’ better access to early investigations, especially in the community.

But he did not go as far as suggesting everyone is able to self-refer, arguing that if ‘everyone who potentially has symptoms of cancer’ was given an appointment for a scan or with the oncology team, ‘the NHS would collapse overnight’.

‘Our ability as primary clinicians to filter and make judgements is an important part of the sustainability [of the NHS],’ he added.

Current NICE guidance on the threshold for a cancer referral is a 3% chance the patient has cancer.

When asked to further explain the comments, the RCGP told Pulse that Professor Marshall was not calling for a lowering of the NICE guideline threshold, but did not clarify if he meant GPs should lower their threshold in an attitudinal sense.

Last week, health secretary Sajid Javid told MPs in the House of Commons that ‘through the pandemic there have been 300,000 fewer urgent cancer referrals than were expected’, which could potentially mean ‘as many as 20,000 missed cancer diagnoses’.

But it comes as new research, published yesterday in the British Journal of General Practice, found that urgent two-week wait referrals for suspected cancer by GPs have more than doubled over ten years.

In 2018/19 there were over 2.2 million urgent referrals, and in 2009/2010, there were 903,011. 

The 2.2 million urgent referrals in 2018/19 resulted in 163,000 people diagnosed with cancer – half of all cancers registered in England that year.  

The paper found that an extra 66,172 additional cancer diagnoses were made after GP urgent referral in 2018/2019 compared to 2009/2010, a 68% increase in cancers picked up.

Approximately seven in 100 people urgently referred are diagnosed with cancer.

Lead author Dr Thomas Round, an East London GP and researcher at King’s College London, said: ‘While we saw a drop in urgent referrals during the height of the pandemic, these have now recovered to pre-pandemic levels. 

‘This is a testament to busy GPs and their teams who are delivering over a million appointments every day.’

Improved artificial intelligence (AI) and training of receptionists would also aid GPs in improving rates of early cancer diagnosis, RCGP’s adviser suggested to MPs last week.

Dr Richard Roope, clinical adviser for cancer to RCGP, was providing evidence to the House of Commons health and social care committee’s inquiry into late cancer diagnosis in the NHS.

Click to complete relevant cancer CPD modules on Pulse Learning.


Visit Pulse Reference for details on 140 symptoms, including easily searchable symptoms and categories, offering you a free platform to check symptoms and receive potential diagnoses during consultations.


Please note, only GPs are permitted to add comments to articles

Simon Gilbert 22 September, 2021 5:31 pm

“Last week, health secretary Sajid Javid told MPs in the House of Commons that ‘through the pandemic there have been 300,000 fewer urgent cancer referrals than were expected’, which could potentially mean ‘as many as 20,000 missed cancer diagnoses’.”

At a 3% risk referral rate the cancer clinics should have a pick up rate of higher than 3%, as their patients will include some at 3% risk, some at 4% risk, some at 20% risk, some at 50% risk etc.
It is unlikely the 300,000 fewer referrals are evenly distributed in this cohort.

I have no idea what ‘shift mindset’ means – these kind of statements over what GPs need or should do just sound like an attempt at an AI chatbot from 20 years ago and are essentially random white noise.

Chris GP 22 September, 2021 5:55 pm

I’m happy with this – I’ll refer everything if that is what you want – no problemo. Every other patient thinks they have cancer – so yes – please do by pass me all together. The NHS will last about a week after that is implemented – but what the hell – I am beyond giving a f*ck.

Turn out The Lights 22 September, 2021 6:20 pm

As the song goes Chris.My new mantra.

Anonymous 22 September, 2021 8:12 pm


I referred red flag raised psa. Pt got a tel consult after 2 months
I phoned up and begged for an urgent appt
MRI shows ca prostrate

Pt had ? Ca lung on cxr (which btw took 2 months ) I requested ct scan and red flag referral
I got the ct result showed ca lung. Called to see about the red flag referral. Was told it would be after 4 weeks

Our urgent neurology referral was just seen after 3 years!

Don’t tell me about GPs and what we should be doing

Mind you this is NI worst in the U.K. of the 4 countries

James Weems 22 September, 2021 8:35 pm

Does Jeremy Hunt understand our gatekeeper role? How do you think specialists will feel with unfettered access to them?

Turn out The Lights 23 September, 2021 7:34 am

Unfettered access to specialists, they will feel like GPs ,bring it on.Imminent system failure.

David Church 23 September, 2021 8:49 am

Is it about time the Queen disbanded her unhelpful and ‘anti-GP’ College?

Kevlar Cardie 23 September, 2021 9:04 am

In other news, it transpires that the Pope takes holy communion every Sunday and that bears are partial, every once in a while, to a crafty shovel recce in the nearest arboretum.

Bonglim Bong 23 September, 2021 10:45 am


David Banner 23 September, 2021 11:08 am

So imagine if we did 2WW refs on ……
– seborrhoeic warts
– cervical lymphadenopathy
– 20 yr olds with IBS
– headache
– menorrhagia
– sebaceous cysts
– incidental anaemia
etc, etc, etc, etc
We’ve been thanklessly sorting the wheat from the chaff for decades, and bearing the medicolegal risk, but if you really want a tsunami of benign tripe with a microscopic risk of malignancy then we’ve got an infinite amount to shove down the 2WW pipe.
And that self-referral model would be grimly hilarious, as all our heartsinks and hypochondriacs would bypass us useless GPs with a letter from Dr Google, that miserable robo-doc who thinks everyone has cancer. Cue car crash……

Dylan Summers 23 September, 2021 11:39 am

The referral threshold of 3% is not a “mindset”, it’s national policy.

Doesn’t matter if I come to work with the “mindset” that I will make a 2ww for everyone, I can only do so in line with the tickboxes.

Patrufini Duffy 23 September, 2021 12:49 pm

I refer everything now. It’s liberating. And you can then say “you’re under the hospital now, I cannot help you further”.

Katharine Morrison 23 September, 2021 1:34 pm

This is just plain silly. It would be better to adequately deal with the people we think do have cancer and concentrate on cancer delaying tactics eg reduce obesity, cut smoking, promote exercise.

q b 23 September, 2021 1:35 pm

you know what, screw you RCGP.

we refer per the guidelines.
if the guidelines from sec care are shit, our referrals will be shit. if accidentally tick the wrong box theyll send it back and not be sensible about it.

protect us from the hate instead of stabbing us in the balls everyday.
get your heads out of your backsides.