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Cancer diagnosis – woeful performance, or the reality of general practice?



As GPs we get used to being beaten up in the press; hauled over the coals for this lamentable failing or that shocking inadequacy. It is still a bitter pill to swallow, however, when you are lambasted for failing to achieve a target that belongs to someone else.

The BBC reported recently that ‘under NHS targets, 95% of people with suspected cancer should be seen by a specialist within two weeks. But the data indicates that this target was missed in more than half of the 4,000 GP surgeries sampled’.  The article goes on to report how woeful our figures really are – 59% of GP practices achieve less than 50% and some practices less than 10%. A cancer target of 95% where only 10% is achieved? My goodness we are bad, aren’t we? Before we all decide to give up and let someone else have a go, however, let’s just have another look at that target, and what the figures from NHS England actually mean.

There is indeed a 95% target around cancer referrals, and it is this: 95% of those patients referred by their GPs under the Two Week Rule (TWR) should be seen within those two weeks. It is a target for hospitals to make sure they really do see patients within the two week period, with 5% wriggle room for those few inevitable cases where the system breaks down. The NHS England league tables, on the other hand, are not based on a target at all. They have simply looked at all those who have been diagnosed with cancer, and then the percentage of those cases that were referred under the TWR, as opposed to any other route.

So what of the NHS England data? Does it make sense to rank practices on the basis of how many cancer patients are seen under the TWR, and does the implication that the highest percentages indicate the best practice hold water? There are many routes a patient might take on their journey to a cancer diagnosis, and surely what really matters is not how they got there, but whether or not there were unnecessary delays along the way. Many of my patients, for example, are diagnosed through the breast and bowel cancer screening programmes. Now these patients could be referred back to me with their abnormal mammograms and FOBs for a TWR referral – it would do my figures no end of good if they did – but that would hardly improve patient care. Then there are those patients I see where a TWR referral is far too long – acute leukaemia, for instance – and emergency hospital admission is required. Am I to regret getting on the phone to the on-call team because I might slip a place or two in the league table?

Other patients, quite rightly, will take themselves to accident and emergency when they first present with symptoms – a first seizure from a cerebral malignancy, for instance, or an acute bleed from a gastric cancer; still others will be diagnosed with cancer after an appropriate period of watchful waiting in the hospital – a slowly rising PSA for instance. All of these patients appropriately referred and diagnosed without delay and without mention of the TWR. What is the ideal percent of patients who should be referred under the TWR, I wonder? Even NHS England states that the figures are ‘not a clear measure of performance’.

Then comes the harder part, those patients who do present to their GP, who have cancer and may have typical red flag symptoms or may have an illness which is far more vague and challenging. We have to be careful here, because there are too many real life stories of patients who see their GP and are not listened to, or are fobbed off; patients who attend again and again, knowing there is something seriously wrong with them, but not feeling sufficiently empowered to insist on action being taken. We must not dismiss these stories, and there is always the need for doctors to improve the care they give, but neither should we be so afraid of missing cancer that we become defensive. The only way that I could guarantee that I never miss a case of bowel cancer would be to refer every patient with bowel symptoms for a colonoscopy under the TWR. My TWR percentage would be magnificent, but my local bowel consultants would be tearing their hair out and, more importantly, I would be putting my patients through unnecessary anxiety and investigations.

General practice is about dealing with uncertainty, knowing when to refer and when to spare the patient from a referral. We have learnt to tolerate this, and so do most of our patients when we talk to them one to one, but our society is becoming increasingly intolerant of any uncertainty. Politicians and the charitable sector are too quick to issue sound bites about their patient care without seeing the bigger picture. Indeed, Stuart Barber, from Beating Bowel Cancer, said it was ‘intolerable’ that patients were having to wait. I don’t want any individual patient with cancer to have to wait either, but we have realise that the more sensitive we make our TWR criteria, the less specific they become – and the more patients we have to put through the trauma of a TWR referral, with all its attendant worries and the risks of investigation.

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68