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Missed cancer treatment targets raise concerns over capacity to implement new NICE guidance



NHS trusts breached the 62-day cancer treatment target over the summer, the third quarter in a row the target has been missed this year, latest statistics have revealed.

The figures came just as NICE set out draft guidance to boost GP urgent referrals for suspected cancer, leading to concerns waiting targets will slip further as hospitals are faced with up to twice the current volume of investigations.

The waiting times, published by NHS England, showed that nationally, 83.5% of patients received treatment for cancer within 62 days of their initial referral – compared with the national target stipulating 85% should be treated within this time.

This was slightly down on figures for the previous two quarters, when the target was also missed with 84.1% and 84.2% of patients treated in time.

Leading GP cancer experts said the missed targets showed the system was under strain and would likely get worse if the draft NICE guidance is carried through – but that this should prompt policy makers to increase resources for cancer investigations in both primary and secondary care.

The draft guidelines, released today lowered the threshold for the positive predictive value of symptoms that should trigger a cancer assessment from 5% to 3%, meaning that GPs will be required to refer patients aged over 40 with unexplained weight loss and abdominal pain and those aged 60 and over with weight loss and new-onset diabetes among other new recommendations.

Dr Richard Roope, cancer lead for both the RCGP and Cancer Research UK, and a part-time GP in Fareham, Hampshire, told Pulse waiting times were being missed partly because of the loss of cancer networks since the NHS was reorganised in April 2013, but said an increase in pressure on the system could provide a necessary lever for greater investment in staff as well as imaging technology and other tests.

Dr Roope said: ‘The missed targets are partly pressure on the system, but also the cancer networks came to an end at the end of March 2013 and they were much better resourced in terms of manpower, and there was much more active engagement on two-week wait, and 31- and 62-day targets.

‘When that all changed and strategic clinical networks came in, that manpower was significantly reduced.’

He added: ‘There would inevitably be concerns there will be even more pressure on the system with the new NICE guidance, but to a degree it is one of those situations where, until you have that pressure nothing is done about it – what is the motivation to invest more and improve the service?

‘So, for example, there is going to be no extra investment in CT scanners unless they are all fully booked – whereas, if the demand goes up the supply might. And hopefully, as these are only draft guidelines we have time to address some of the infrastructure and personnel issues before they are introduced.’

Professor Greg Rubin, professor of general practice and primary care at Durham University and lead investigator on the national audit of cancer diagnosis in primary care, agreed the increased referrals should put the onus on policy makers to increase capacity for investigations.

Professor Rubin said: ‘It is a question of public policy whether we want to use our healthcare resources to detect cancer earlier in people with lower risk symptoms by using an urgent referral pathway.

‘When people say, we can’t do this because it is going to increase referrals – what I think the message is going to be, yes, NICE knows it is going to increase referrals and that is what it wants to happen – so somebody is going to have to find ways to deal with that.’

He added: ‘Individual GPs do not have a responsibility for limiting referrals, they have a responsibility to making appropriate referrals. And if NICE advise it is appropriate to refer at this lower threshold, then that is the sanction that they require.’

Dr Andrew Green, chair of GPC’s clinical and prescribing committee agreed an increase in referrals could lead to better resourcing of cancer services, but cautioned that outcomes could worsen if waiting times are impacted in the short-term.

Dr Green said: ‘The guidance will inevitably result in increased referrals, and indeed that might not be a bad thing, and for cancer mortality to improve the relentless pressure on GPs to reduce referrals needs to end.

‘Secondary care trusts will find it increasingly hard to meet targets, and there is a danger that outcomes might worsen if waiting times for the most at-risk referrals increase due to the higher numbers of low-risk patients. This is a politically sensitive area and we also need to ensure that the secondary sector does not use this increased activity as a magnet for additional funding, so reducing primary care’s proportion of the total budget still further.’

Dr Green added: ‘My hope is that CCGs will be able to find imaginative ways of meeting this need, and that might include practices being enabled to provide more investigations than they can at the moment.’

>>>> Clinical Newswire