Jeremy Hunt's plan to shame GPs with low cancer referrals is not the answer
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Version 0 of 1. The health secretary, Jeremy Hunt, wants to name and shame GP practices with low cancer referral rates. The NHS Choices website will mark low-referral GP practices as "red", or "green" if they refer more. This is in response to significant variations in cancer diagnoses across England, which is being attributed to GPs not referring patients early enough. According to figures from the Royal College of General Practitioners , three-quarters of patients with cancer are referred after one or two GP consultations. There is certainly room for improvement. Many high-risk symptoms are easier to refer, such as a persistent cough, a change in bowel habits or weight loss. It is the non-specific symptoms such as tiredness that are often the most challenging. Pancreatic cancer is a notoriously difficult diagnosis and can present with just malaise, loss of appetite, new onset diabetes or back pain, all of which we see on a daily basis in general practice. Pancreatic cancer is the ninth most common cancer in the UK but the fifth most common cause of cancer death. GPs have clear guidelines on "two-week wait" referrals for all cancers, whereby anyone who presents with certain high risk signs or symptoms, known as "red flag", should be referred straight away and seen in hospital within two weeks. The criteria for referral is very specific and does not take into account a GP's intuition or non-specific symptoms. In our practice we audit our two-week wait referrals, to ensure firstly that the patient has been seen by a specialist and hasn't been lost in the system and secondly, to see if a cancer diagnosis was made. The vast majority of our referrals are, reassuringly, not diagnosed with cancer. Demographics also play a huge part when it comes to looking at cancer diagnosis and mortality rates. I trained as a GP in an affluent semi-rural practice and often saw the worried well. The appointments were longer, less pressured and many patients attended for an "MOT". It was then that I saw my first malignant melanoma when a "well" patient came to have all their moles looked at. It was a very early presentation and they made a full recovery with no spread or recurrence of the disease. I now work in a large urban practice with diverse health beliefs. There is more deprivation and medical complexity and many patients, especially men, will present after weeks or months of worrying symptoms. For some of our patients, their proximity to hospitals or cultural beliefs mean that they will bypass GPs altogether and attend A&E departments for first presentation of symptoms. Most GPs do not see lots of new cancer diagnoses every year, though most of us will make one or two cancer referrals a day. Nationally, only 10% of two-week referrals turn out to be cancer, which is similar to those referred from our practice. But we do see lots of coughs, colds, malaise, aches and pains. The danger with this "kneejerk" name and shame policy would be that we would see a sharp rise in anyone with a cough or cold being referred. As a result, this will quickly saturate the capacity of cancer clinics and delay investigations. The last thing that we would want is the two-week wait to increase to a four-week wait or even longer. Statistics for every practice are already available online for GPs and the public to look at. GP practices are aware if they are high or low referrers; it seems that the new proposals would add nothing but be tantamount to "naming and shaming" doctors. Any analysis of cancer referral rates must look at the patient demographics of a practice, its cancer prevalence and other parameters such as whether it is an outlier in other respects. There will indeed be some GP practices that are a cause for concern, but this is usually already apparent to commissioning groups and NHS England, and it would make more sense to performance manage these locally rather than adopt a damaging culture of blame and fear. |