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​Patients not being referred under two-week wait rule, data suggests

Most patients attending the GP for the first time with key red flag symptoms are not referred straight away under the two-week wait pathway as per national guidance, preliminary research suggests.

However, the RCGP said GPs are working ‘exceptionally hard’ on the timely diagnosis of cancer. 

The researchers from Exeter University are now planning more work to investigate the potential clinical implications of their findings.

Analysis of patients presenting with haematuria, rectal bleeding, breast lump, post-menopausal bleeding, dysphagia or anaemia for the first time showed that only a minority were referred within the next 14 days.

Overall there was also a high level of ‘discordance’ between the NICE guidelines on urgent referral and GP decision including for more clear-cut symptoms such as breast lumps, data presented at the National Cancer Research Institute annual conference in Glasgow showed.

For patients presenting with anaemia for the first time between 2014 and 2015 – the most common symptom looked at – only 2% were sent through the two-week pathway, which the researchers said may be down to the ambiguous nature of the symptom. Around 10% of patients presenting for the first time with rectal bleeding were referred within 14 days.

The highest levels of quick referral were seen for breast lumps (48%) and post-menopausal bleeding (43%).

Researchers also found that younger patients, those with comorbidities and those living in more deprived areas were less likely to receive a two-week wait referral.

Study author Dr Bianca Wiering said some of the patients who did not receive a two-week wait referral will still have been seen quickly because they received an urgent referral outside the formal two-week wait pathway.

Dr Wiering said: ‘Having said that, even if these groups are added together, there is still a large number of patients not receiving an appropriate referral.’

She added: ‘We are currently looking into how many patients who are not referred using a two-week wait referral or an urgent referral go on to develop cancer. If this is a substantial percentage, then the implication would be that education and encouragement to follow guidelines would lead to improved diagnosis and ultimately survival.’

But Dr Samuel Finnikin, a GP in Sutton Coldfield, countered that looking at coded data was fraught with problems because symptom-related codes can be very context-dependent and prone to error.

He said: ‘The bottom line is, these are important findings, but context is key. There are all sorts of reasons why patients may not be referred after (apparently) presenting with worrying symptoms, including coding errors, alternative explanations and patient choice.’

Professor Helen Stokes-Lampard, Chair of the RCGP, said: ‘GPs are working exceptionally hard on timely diagnosis of cancer, and research shows that nearly 80% of all cancer cases are now referred after only one or two consultations.’

It comes as research in the British Journal of General Practice concluded that there was a range of reasons why 5% to 7% of patients cancel or do not attend their urgent hospital appointment.

These included systems flaws such as appointment letters arriving too late or being sent to the wrong address. The study also found that some patients did not realise their appointment was urgent or were scared of invasive tests and were not informed of sedatives available.

Deprived patients were more likely to have ‘chaotic lives’ meaning cancer was not perceived as a priority or they had difficulty accessing hospital due to finances, transport or complex health issues. And in some cases GPs expected patients to chase up the practice if they did not receive an appointment rather than using administrative staff to check appointments had been booked.

GPs also described struggling to undertake appointments involving suspected cancer referrals in 10-minute timeslots.

Professor Stokes-Lampard said the research ‘provides further evidence to support the college’s calls for 15-minute appointments as standard for our patients with complex needs’.