According to RCGP chair Professor Martin Marshall, GPs need to ‘shift mindset’ to ‘lower thresholds’ for cancer referral. Or rather, for ‘cancer’ referral, given that the current NICE-suggested positive predictive value threshold for symptoms is already so eye-wateringly low that the majority of patients referred are far more likely to end up diagnosed with anxiety than cancer.
This suggestion throws up at least three paradoxes:
1. Lowering thresholds for referral might ensure fewer cancers are missed. But as things stand, this can only be at the expense of delaying those cancer diagnoses for the minority who actually have it – because the diagnostic bottleneck is at the pointy, hospital end, and increased referrals just makes this investigative delay worse.
2. The lower our cancer threshold becomes, the more it makes our job as gatekeepers, and therefore GPs, pointless. And if this sounds like protectionism, it is. Yes, it protects a sacred GP role. But it also protects the hospital from meltdown. And it protects patients from an endless hell of bewildering tests and follow up appointments to deal with the incidentalomas found via the inevitable 2ww CT CAP.
3. There’s not much lower the threshold can actually go, unless Prof Marshall-inspired revised NICE cancer guidance suggests that the new criterion for referral is simply that the patient is alive, and therefore at risk.
So I’m sorry Prof, but I’m not sure this ‘shift mindset’ stuff makes much sense, but I am sure that overwhelming hospitals and undermining of our gatekeeping USP makes no sense. Also, there’s nothing here about monkeys.
Dr Tony Copperfield is a GP in Essex. Read more of Copperfield’s blogs at http://www.pulsetoday.co.uk/views/copperfield