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My mind is set on ignoring cancer advice

fruit and veg prescription

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


David Church 27 September, 2021 12:37 pm

Aw, c’mon Copperfield, we have been given a temporary ‘win, win, never lose’ situation.
I say temporary as it will not last long before GPs are blamed for the collapse of the Hospital Cancer services due to over-referring, but, in the meantime……
Now everyone who might be at risk (alive, as you say), can be referred and will be seen within 2 weeks.
We can tell them we don’t think it is cancer; we can put in the referral that we don’t think it’s cancer (unless it blatantly obviously is, of course), and we can use phrases that sow seeds of doubt in the consultants minds.
Consultants will do loads of investigations.
If patient tunrs out to have cancer now, look how brialliant the GP was for noticing it so early;
If patient does not have detectable cancer, look how brilliant the GP was for saying it wasn’t, but how considerate for referring me anyway to be sure;
If the patient develops cancer at any future time many years later – look how brilliant the GP was for detecting it years before that stupid Consultant admitted it was obviously cancer after such a long delay while he could not find what was obviously there all along – cancers are quite slow growing, of course!
So, GPs are brilliant, and all errors are fault of the Consultant; for now….

Decorum Est 27 September, 2021 1:12 pm

Aw, c’mon Copperfield, the Professor is just feeling a bit needy, so is jumping on the very popular ‘GP bashing’ band wagon.
(OK, maybe he is a bit confused as well……God help the poor soul)

Dr N 27 September, 2021 3:02 pm

Aw, c’mon Copperfield, patients love the new GP fresh from training as they refer everything, do a blood test for everything and prescribe for everything. Lets not be a grumpy old GP who doesn’t refer needlessly, doesn’t investigate needlessly and doesnt’ prescribe needlessly. And dont forget a massive 11% of 2WW referrals actually have real cancer.

Patrufini Duffy 28 September, 2021 1:40 pm

Metastatic anxiety. Is the most costly and crippling dangerous condition.

You see, they don’t allow patients *or generic public (there is a difference) to self refer moles, rectal bleeding and blah blah bloating. Why? Because they’d crash the system, like loo roll in a petrol station.

Keith M Laycock 2 October, 2021 5:04 pm

I thought I’d just read that the jolly GP had to phone to ask a jolly Hospital Doctor / Consultant for permission to do so before putting in the referral – Apparently, this brain-blast will keep referral numbers down.