Exclusive GPs have been told they must conduct FIT tests before referring patients with suspected bowel cancer to secondary care, Pulse has learned.
Last year, London GPs were blocked from referring patients with urgent suspected bowel cancer to hospitals based on symptoms alone and without a positive FIT test, under changes to local NHS guidance brought about by Covid-19.
But now, some areas have permanently raised thresholds for two-week-wait referrals for lower gastrointestinal cancer.
This goes against current NICE guidance NG12, which allows GPs to refer patients based on just their symptoms such as a change in bowel habit.
Doncaster LMC chief executive Dr Dean Eggitt told Pulse that mandatory FIT tests have been embedded in referral processes in the area as part of a new eight-page referral form from the South Yorkshire and Bassetlaw ICS Cancer Alliance.
The form, seen by Pulse, said that ‘with the exception of patients presenting with rectal bleeding, abdominal/rectal or anal mass all patients with suspicious of bowel cancer NG12-compatible symptoms must have a FIT prior to instigation of referral.’
It added that those with a positive FIT result should be referred via the two-week wait pathway, while those with a negative result who ‘do not need’ a referral should be ‘reassured and safety-netted as required’ or referred on ‘an alternative pathway’.
However, patients with a FIT result of between 4 and 9.9 should only be referred if there is ‘strong clinical suspicion and/or evidence of anaemia’ with either low or raised ferritin or with thrombocytosis, the form said.
A referral to gastroenterology ‘should still be considered’ for those with iron deficiency anaemia and a negative FIT result but via a non-cancer pathway, it added.
GPs must confirm that all patients being referred have undergone a FIT test as well as bloods taken within the last three months as ‘mandatory actions prior to referral’, it said.
Dr Eggit told Pulse the complicated new requirements are ‘very frustrating’.
He said: ‘We try to refer patients but struggle. And for a cancer referral, it’s supposed to be as fool-proof as possible.’
Meanwhile, the process could add an extra week before patients receive a diagnosis, leaving them in a ‘holding state’ in general practice before referral and meaning the two-week wait has effectively ‘gone out of the window’, he added.
Dr Eggitt said: ‘It’s created this holding state of patients who won’t yet be counted because the two-week wait clock doesn’t actually start until you’ve started the referral – which means that it’s going to be held in general practice potentially an extra week whilst we await the result before we refer.’
The additional requirements also add to rising GP workload, he said.
He told Pulse: ‘Everyone is just overwhelmed with workload and they’re trying to reduce the workload for the specialists by asking the GPs to do it.
‘That just means that we’re doing what everyone else needs to do in hospitals – we take the history, do the examination, what else can fit into general practice? We can’t do everybody’s jobs for them.’
In Essex, a cancer update sent to practices in April said that guidance was changing to say that ‘all lower GI two-week wait referrals will need to have an accompanying FIT’.
The NHS Basildon and Brentwood CCG update, seen by Pulse, said: ‘Previously FIT was only for patients that were “low risk but not no risk”. However, emerging evidence has indicated the importance of FIT in refining the patient pathway in addition to emerging evidence around FIT and patients with rectal bleeding.’
University of Exeter professor of primary care diagnostics Professor Willie Hamilton told Pulse that ‘quite a few’ areas have moved to asking GPs for FIT tests on two-week wait referrals as well as ‘lower-risk’ patients.
He said: ‘This “FIT them all” policy was sensible in the era of restrictions on colonoscopy/imaging resource and may indeed be sensible after the pandemic delays have abated.’
However, he added that ‘many things need to be sorted out’ if this were to become a long-term pathway, such as what FIT level requires onward referral and whether it is a ‘patient or GP-friendly’ pathway.
GP cancer experts have previously warned that a negative FIT test result does not rule out cancer altogether.
But a study published in July concluded that GPs can confidently avoid secondary care referrals for colorectal cancer investigation for patients with a negative FIT result.