GPs should manage certain patients with suspected colorectal cancer with advice and guidance (A&G) from secondary care colleagues, NHS England has said.
New guidance, first published in draft form by the Association of Coloproctology of Great Britain & Ireland (ACPGBI) and the British Society of Gastroenterology (BSG) in June, said that GPs should downgrade some urgent colorectal cancer referrals based on new FIT thresholds.
It said that FIT tests should be used as a triage tool, with patients testing below fHb 10μg Hb/g not referred via the urgent cancer pathway even if their symptoms fulfil NICE criteria.
It added that ‘some patients with symptoms of suspected colorectal cancer may be managed in primary care if fHb <10μg Hb/g’, as long as ‘appropriate safety netting is in place’ and the GP does not have ‘ongoing clinical concern’ about any ‘persistent and unexplained symptoms’.
Now NHS England has urged ‘all GPs’ to implement the guideline’s recommendations ‘in full’.
In a letter sent to practices and PCNs last week, it reiterated that those with ‘a FIT of fHb <10μg Hb/g, a normal full blood count and no ongoing clinical concerns’ should not be referred on a lower GI urgent cancer pathway but should be ‘managed in primary care or referred on an alternative pathway’.
It said that ‘appropriate safety netting must be in place’ when patients are not referred, which could include ‘using advice and guidance via eRS [the NHS e-referral service] to guide management of patients with persistent or troublesome symptoms’.
In an accompanying letter to trusts, NHS England added: ‘The BSG/ACPGBI FIT guidance recommends GPs take responsibility for managing those with a FIT fHb <10μg Hb/g and no ongoing clinical concerns in primary care.
‘Secondary care should make sure systems are in place for GPs to easily access advice and guidance to inform their referral decision.’
NHS England’s GP letter added that clinical teams should also ‘consider’ safety netting via:
- Providing the patient with ‘clear information about who to contact if they develop new symptoms or if their existing symptoms worsen’
- Offering a second FIT test if ‘ongoing clinical concerns remain’
- Referring the patient to a ‘non-specific-symptoms urgent cancer pathway, if appropriate and there are ongoing concerns about possible cancer’
- ‘Management of FIT-negative patients in an outpatient setting following referral on a non-urgent pathway’, where this is in place
Meanwhile, NHS England also suggested that if GPs refer patients with FIT results below the threshold because they have ‘ongoing clinical concerns’, hospital colleagues can bounce these patients back to primary care if they do not agree these ‘clinical concerns’ are present.
Its letter to trusts said: ‘Where patients with a FIT fHb <10ug Hb/g are referred to secondary care and it is agreed at clinical triage, based on referral information which is confirmed following direct communication with the patient, that there are no ongoing reasons for clinical concern, secondary care teams should not offer an endoscopic investigation but should consider the following options.
‘Following a consultation where it is communicated with the patient that they are no longer being investigated for potential cancer, discharge the patient from the lower GI pathway for safety netting delivered by primary care or secondary care.’
It added that patients could also be moved to a routine secondary care pathway if ‘ongoing non-cancer related clinical concerns remain’, referred to another cancer specialty or non-specific symptoms pathway if there is suspicion of another type of cancer, or managed on a ‘non-urgent referral pathway’.
NHS England also said that GPs should:
- Provide patients with ‘advice on the importance of completing a FIT test’
- Build text message reminders ‘into the pathway to encourage patients to complete and return their FIT kit‘
- Ensure they include FIT results on referral forms for any urgent cancer referral
The letter said: ‘Waits on the lower GI pathway have lengthened more than for any other tumour group since the pandemic.
‘By fully implementing the use of FIT in the symptomatic lower GI pathway we will be able to spare patients unnecessary colonoscopies, releasing the capacity to decompress the symptomatic lower GI pathway and ensure the most urgent symptomatic patients are seen more quickly.’
Hospitals have been ordered to reduce the number of patients waiting too long for cancer investigation amid GP referral rates that are currently one-fifth higher than before the pandemic.
Meanwhile, recently announced changes to the PCN incentive scheme include an amendment to an indicator recognising PCNs for ensuring that lower GI fast-track referrals for suspected cancer are accompanied by a FIT – changing the permissible time between FIT result and referral from seven to 21 days.
And in August, the bowel cancer screening programme was expanded to patients aged 58, who will now be sent a FIT test once they become eligible.
NHS England plans to gradually expand bowel cancer screening eligibility to everyone over the age of 50.
READERS' COMMENTS [18]
Please note, only GPs are permitted to add comments to articles
You wanted it.
You sold it.
You scared them and worried them.
Now deal with it and the storm of referrals.
GMC comes first. Patient comes first (or third apparently). Refer when in doubt. Otherwise, give the PALS number and NHSE helpline number 0300 311 22 33.
In my book, the responsibility for rejecting a referral lies with the clinician rejecting it (not the GP)
GPs didn’t bring in FIT as a rule out screening test. If a GP has referred despite below threshold -they will usually have concerns (e.g. alteration in bowel habit, blood, mucous, a mass) -they don’t do this for fun!
NHSE siding with specialists without the backing of NICE is ‘nice’ but doesn’t constitute a defence.
“So why did you not refer this patient”; “well m’lud NHSE said I can’t”: “‘unless you have concerns’ and you should have had concerns as the patient turned out to have cancer”
The GI surgeons seem to believe in fit for GPs, but don’t actually when it comes to their own practice….
Then they suddenly come over all defensive… well I had space to just do a quick sig… and and that biopsy was precautionary…so the histology showed neoplasia.. that doesn’t prove that the test wasn’t 100% reliable
Sounds very much like a protocol for the first outpatient clinic.
Consultants are allowed to see patients, give them advice and discharge them without intervention.
The belief in a ‘perfect test’ is one which makes me more sceptical than anything else.
If they would accept this is a logical impossibility we could have some discussion.
We are set for even worse performance in Health Outcomes for colorectal cancer; UK is already the egregious outlier in international comparisons on this criterion.
Having bypassed NICE, will the BSG and NHSE now be conducting the evaluation to show that the extra 1 in 1,000 patients tested whose cancer is missed is a correct assumption?
Yep PAG will slaughter you via NG 12 & here we have helpful alternative management.
As I recall FIT was never used in such a manner (high risk) hence NG 30 if I remember correctly.
FYI cancers diagnosed in FIT -ve locally too
Aside from argument does FIT -ve need one or two tests?
Be scared or have water tight safety netting
The NHS – fobbing the patient off, via the GP scapegoat. Dead old plan. Ignore managers and politicians and do as one is trained to do.
Maybe if they stopped scoping barn door IBS patients under 30, we could actually get on with something meaningful? Oh no, we can’t. Because tariffs earn the Trust money. And the GMC wants kebab and beer-bloated patients scoped.
No,If I suspect I will refer.End of.
This strikes me as dangerous and stupid.
Another attempt at responsibility transfer?
“Will my actions pass the Coroner’s Test? If no – refer”.
There should be a test whereby if hospital practice changes and this leads to something being managed in primary care that would have been managed in secondary care 10 years ago, it automatically triggers an uplift to practice income to reflect the extra work, learning and safety netting.
Be interesting to require production from the NHSE of full indemnity in writing (set up by m’learned friends) to cover the inevitable later presentaion of colon cancer after FIT was negative and referral not done.
No covering letter? Then that would be “steady as you go lads”. Follow that spidey sense tingle and refer.
Forget NHSE. They will deny any claims the moment judgement comes in a not so NICE medicolegal case. Refer them. We have a duty of care to our patients not politicians.
Had a FIT negative lady I was worried about due to pain and reduced appetite. Transverse colon tumour after reluctantly scoped. Thankfully localised disease. FIT plus faecal DNA (not available) only gets to 95% sensitivity. 5% of a very common tumour is a lot of people.
A & G another symptom of this government’s new austerity and keep patients out of hospitals? and yet more attempting to foil
and deter the GP trying to help and refer their patient? Also, presuming a GP has the time, among the work overload, to do the
A & G for patients needing this speciality and others, how lucky will the GP be to synchronise their time with the availability of the A & G specialist concerned ( who may not even be the top dog consultant anyway, perhaps just a non-doc instead, neither of whom will know the patient). I wonder what T Coffee, Health Secretary, formerly a worker for Mars, thinks about this: perhaps this grand new scheme is one of her brainwaves even, anything to reduce public spending. A & G Dermatology and others too.
Fit test up to 90% accurate?
43000 new cases of colorectal cancer per year in UK?
Over 4000 colorectal cancers not detected by FIT per year?
My maths must be wrong.