Cancer plan undermined by PCTs

When the government unveiled its £750 million cancer strategy for England in December 2010, the emphasis fell squarely on early diagnosis.

Endoscopy is among the procedures GPs are blocked from accessing (Photograph: SPL)
Endoscopy is among the procedures GPs are blocked from accessing (Photograph: SPL)

As part of the drive to save an additional 5,000 lives a year by 2014/15, GPs would be able to send patients for direct access to scans, such as MRI and flexible sigmoidoscopy, and reliance on referral through secondary care would fall.

But a GP investigation shows that GPs' use of such scans is now under greater scrutiny and, in some cases, access has been scrapped altogether.

More than a quarter of PCTs (28%) plan to investigate practices' use of diagnostic scans, or are doing so already, and many are instigating measures to cut inappropriate use.

Some trusts are going further: nine PCTs are identifying excessive users and two trusts are considering upper and lower targets on access.

Five PCTs have decommissioned some direct access scans altogether, in some cases after the strategy was announced.

The investigation also found that overall provision of direct access scans was extremely patchy. Some PCTs offer access to a whole gamut of tests while neighbours commission no access at all.

GPC negotiator Dr Chaand Nagpaul says blocking access to scans risks 'turning back the clock'. 'Clearly, the government agenda for early diagnosis of cancer is a major plank of the cancer strategy, and needs GPs to have access to diagnostics.

'Giving GPs direct access to diagnostics is good for patients because it leads to prompt and timely diagnosis, reduces delays and it does offer the opportunity to make cost savings.'

Dr Nagpaul believes restricting access is a retrograde step. 'Cast your mind back to a few decades ago, to restrictions on GPs accessing x-ray.

'General practice has transformed because it got access to these scans,' he says. 'It would be turning the clock back to restrict GPs accessing diagnostics again.'

Findings are concerning
Cancer Research UK's director of policy, Dr Sarah Woolnough, says the findings are concerning.

'As we believe the key reason our cancer outcomes lag behind the best performing countries in the world is late diagnosis, it would be worrying if GPs had less support to help ensure the early diagnosis of cancer.'

Dr Woolnough says removing or capping access would 'contradict' the aim of the cancer strategy. She adds: 'If the decommissioning of direct access to tests was being made on cost grounds, we would want PCTs to reconsider.'

RCGP imaging lead and Yorkshire GP Dr Nick Summerton says commissioning of direct access scans is haphazard and must improve.

In some cases, difficulty accessing scans means GPs are attempting to investigate symptoms quicker, and reduce anxiety for patients, by inappropriately using the two-week urgent referral pathway, Dr Summerton says. Failure to commission direct access scans can therefore 'clog up' this urgent pathway, he points out.

Commissioning guide
Dr Summerton's team at the RCGP's Centre for Commissioning has published a commissioning guide on the subject. He is 'absolutely sure' commissioning groups will want to add to the roster of investigational tools available to GPs.

He hopes the guide will help them overcome the difficult task of planning such services and find the balance between increasing access and improving appropriate use.

In the autumn, DoH cancer czar Professor Sir Mike Richards will publish official guidance on direct access scans as the strategy continues its rollout.

Dr Summerton is adamant that appropriate use of direct access scans is key to ensuring costs are minimised while important investigational work can go ahead.

But persistent problems need to be overcome. Aside from patchy commissioning, some scans are being excessively and inappropriately accessed while GPs elsewhere are being denied access to appropriate tests.

Commissioners will need to address the shortcomings in how GPs are able to investigate cancer to make any dent into that 5,000-lives survival target.

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