Plans to bypass GP for some cancer tests are underway, says health secretary

Plans for patients to bypass the GP and directly access some diagnostic tests for suspected cancer are being considered, health secretary Steve Barclay has confirmed.

Speaking with the Telegraph, Mr Barclay said senior clinical leaders were looking at new ways to ‘design out bottlenecks’ and ensure people with worrying symptoms do not get held up by GP waits.

It would mean some patients going straight to an NHS diagnostic centre without a GP referral, he said.

‘We are very much looking at those patient pathways,’ Mr Barclay said in the interview, explaining ‘considerable work’ was being done on redesigning the system.

‘Where there are bottlenecks in the system of referral from the GP, is there scope to go direct to the relevant diagnostic test or to the [specialist] clinician?

‘Breast cancer is a good example because almost always the GP refers on [for scans or to a hospital specialist] and therefore there’s an opportunity to design out bottlenecks in the system,’ he added.

It is not the first time the idea has been raised with proposals for patients being able to self-refer for some investigations included in the 10-year cancer plan published last year.

At the time, the Government said it was ‘committed to accelerating progress’, for example via ‘working with primary care to trial new routes into the system via community pharmacy and self-referral’.

GPC England chair Dr Katie Bramall-Stainer said Mr Barclay’s plan may sound ‘seductively simple’ but it bypasses the ‘essential’ triage GPs do as ‘expert generalists’.

She said: ‘This suggestion might sound like a good idea, but it will rapidly overwhelm radiology departments, and lead to even longer waiting lists for scans, and potential missed diagnoses – putting yet more pressure on the NHS.’

‘The priority for such an overwhelmed NHS has to be safety. And GPs are integral to safe cancer referral processes – removing us from the equation risks patients falling through the net and those without cancer being put on the pathway by mistake, or missed altogether,’ Dr Bramall-Stainer added.

Professor Carolyn Chew-Graham, a GP and professor of general practice research at Keele University, said people present to primary care with undifferentiated symptoms and it is the task of the clinician to make sense of the symptoms, examine the patient, ask for more information, test out possible diagnoses, and explore the patient’s worries.

‘If the clinician (usually GP) feels that cancer is a possibility, then they may order investigation or make a referral depending on the symptoms and what is found on examination, so with breast lump immediate referral, or with change in bowel habit, FIT test and blood tests are required before urgent referral to lower GI for colonoscopy.

‘My concerns about people being given access to scans are that a person may not know what scan might help to investigate a set of symptoms.’

And she added: ‘People with persistent physical symptoms may refer themselves repeatedly which heightens their health anxiety, uses resources, and is not the appropriate help they need for unexplained symptoms.’

Professor Azeem Majeed, a GP and professor of primary care and public health at Imperial College London, said the motivation seems to stem from the significant delays some patients experience in obtaining GP appointments but that is only one factor in the diagnostic pathway.

‘If patients with potential cancer symptoms can bypass these wait times, it could lead to earlier detection and treatment, thus potentially improving outcomes.

But he added: ‘Even after referral, patients can wait for a long period before they receive a diagnosis and start their treatment.

The example of breast cancer suggests that the plan may not be for every clinical area but for cases where a direct referral to scans or specialists is almost always the outcome.

‘However, even here, appropriate clinical assessment is needed (such as via a telephone or video appointment with the breast clinic) to ensure the right tests are ordered so that diagnostic units are not overwhelmed with referrals.

‘It will also be essential to have a feedback mechanism in place for patients who get scanned, especially if the results are negative. They might still need to see a GP or specialist for further evaluation.’

Successful implementation will ‘rely heavily on thorough planning, adequate resourcing, and clear communication’ to professionals and the public, he noted.

Professor Willie Hamilton, professor of primary care diagnostics at the University of Exeter, said there are a few symptoms where self-referral with a clear protocol may work, breast lumps being one example, but it would need careful evaluation. 

‘But this is not going to revolutionise cancer diagnostics and we have to be careful that this isn’t yet another way of failing to address problems within general practice,’ he added.

‘Not every cancer has a single clear symptom and for many symptoms there are multiple other diseases it could be that then may be missed.

‘If you just go for the test it becomes a substitute for thinking and that’s where errors occur.’

Dr Richard Cook, a GP in West Sussex said: ‘The guy is an idiot, who is looking at untested ways of bypassing an underfunded system, by increasing unfiltered access to expensive investigations.

‘The devil will be in the detail, but it will not change the fact that Barclay is a Tory fool.’