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Cancer self-referrals made little impact on lung cancer diagnoses



Exclusive The self-referral strategy being trialled by NHS England as a route to diagnosing cancer earlier failed to make any major impact on diagnoses in a previous pilot of the approach, Pulse has learned.

The head of the pilot run in Leeds said that the scheme was successful, but it found that giving patients the option to go directly to hospital for a chest X-ray without first visiting their GP had a small effect on cancer diagnoses.

The findings were revealed after NHS England announced a major new programme of work on improving early cancer diagnosis – including self-referral for chest X-rays as a means of speeding up early lung cancer detection.

One pilot of this planned so far will involve offering people in Crewe from ‘high-risk’ areas the opportunity to request a chest X-ray without a GP appointment.

GP leaders have expressed concerns about the move to bypass GPs and allow patients to self-refer, with concerns it could lead to patients undergoing unnecessary, harmful investigations.

NHS England had said that ‘enabling patients to book their own appointments directly with a diagnostic testing unit or hospital diagnostic service could remove the need for them to see their GP, potentially speeding up the process of diagnosis’.

However, an earlier pilot run in Leeds found the introduction of self-referral chest X-rays had minimal impact on lung cancer diagnoses – although the wider programme of work, of which it was a part, was successful in improving early detection of the disease.

The pilot – set up in 2011 by Leeds Teaching Hospitals NHS Trust – involved three initiatives targeting areas of Leeds with poor health outcomes including high lung cancer mortality, particularly in men.

This involved a ‘Got a cough, Get a Check’ publicity campaign to raise awareness of lung cancer symptoms, alongside a self-referral chest X-ray service whereby people over 50 years of age with a cough lasting three weeks or longer could self-present to a hospital chest X-ray clinic without a GP referral.

The programme – which now forms part of routinely commissioned cancer services in the area – also included a series of GP education sessions on early detection, aimed at lowering the threshold for suspicion of lung cancer and increasing GP referrals for chest X-rays.

Dr Matthew Callister, consultant respiratory physician at Leeds Hospitals Teaching Trust and head of the project, told Pulse the self-referral had been ‘useful’ but that results indicated the self-referral route did not change the way cancers were being diagnosed.

Chest X-ray referrals have increased markedly since the project started, from around 20,000 a year in 2010, to over 32,000 last year. However, Dr Callister explained that most additional X-rays have resulted from the increase in GP referrals with around 2,500 coming via the self-referral route.

And while the provisional data – still being verified by Public Health England before publication -show an improvement in one-year survival from lung cancer, reduced emergency presentations of lung cancer and a small improvement in presenting stage of disease, Dr Callister said most cancers were still diagnosed via the GP referral route.

Dr Callister said: ‘I think the self-referral has been a useful aspect of the programme. We have shown that patients are able to use the service appropriately, and our local GPs have been very supportive of the new pathway. Patients are recalled directly for CT in case of a normal X-ray, and patient feedback has been excellent.

‘However, even with the self-referral pathway, most patients were diagnosed with lung cancer following referral from their GP. Our experience would therefore support introducing a self-referral pathway, but only as part of a wider campaign incorporating GP training, lowering referral thresholds and community education.’

Dr Richard Vautrey, deputy GPC chair and a GP in Leeds, said the earlier pilot cast doubt on the value of self-referral.

Dr Vautrey said: ‘Actually whilst a small number of lung cancers were detected I don’t think they were at a significantly earlier stage than would have been the case from direct GP referrals and so the long term outcome for patients was not that different despite the additional expense.’