One in five GPs who had a referral blocked later discovered the patient had cancer, suggesting that thousands of NHS patients’ lives are being put at risk because they are denied a vital early diagnosis.
Some hospitals are breaching the two-week target for urgent referrals, the poll of almost 500 GPs found. GPs reported that trusts are using subtle tricks to limit referrals on the two-week cancer pathway, gaming the target or actively cutting back on direct access to key diagnostic tests.
Restrictions on GP cancer referrals show how hospitals facing a potential £2.3bn deficit by the end of 2015/16 are struggling to cope with rising demand for diagnostic tests.
GP cancer scans
One in eight respondents to the survey said the proportion of cancer referrals downgraded or bounced back was increasing in their area.
Meanwhile, more than half of GPs report that they do not have direct access to two of the most effective diagnostic tests for cancer - MRI and CT scans.
An expert cancer taskforce report endorsed by NHS England recommended last year that all GPs should have access to six key tests - including MRI and CT scans - by the end of 2015.
In some areas, however, GPs reported that under-pressure hospitals were actively withdrawing direct access to diagnostic scans.
The move contradicts NICE guidance last year that encouraged GPs to refer more. Revamped guidance lowered the threshold for GP referrals, specifying that GPs should send patients for tests if their estimated risk of cancer was 3%, rather than the previous 5% limit.
Early cancer diagnosis
NHS England has also publicly backed a goal set by the cancer taskforce that by 2020, 95% of patients referred for testing by a GP should be definitively diagnosed with cancer, or have cancer ruled out, within four weeks.
Yorkshire GP Dr Nick Summerton, a cancer expert who has advised the government on diagnostics, told GPonline he had personally had a cancer referral blocked in the past 12 months. But he said trusts were more likely to use subtle tactics to reduce pressure on the two-week pathway.
‘For a trust to deny access to the two-week wait pathway, that will get them in a lot of bother. To manage demand - delay or dissuade, those are the traditional ways,’ he said.
‘A lot of trusts haven’t changed their referral forms even though the cancer referral threshold has been lowered. If you don’t change the forms, that’s a subtle way of making people stick to the old criteria, which require a higher threshold.’
He said trusts tried to limit referrals on the two-week pathway through methods such as downgrading patients to a check up with a nurse-led clinic, demanding certain tests or examinations are completed before referral, or discussing the pros and cons of a procedure with patients to put them off.
Dr Summerton said it was ‘ridiculous’ for an NHS that runs population-wide screening programmes - which pick up small numbers of cancers in people who have no symptoms - to deny or limit access to scans for people who have had symptoms identified by their GP.
Two-week cancer referral
‘The idea that GPs sending people for screening who turn out not to have cancer is a failure is preposterous,’ he said. ‘GPs need to be able to just get as many people with symptoms as possible through for screening, to pick cancers up early.’
Macmillan Cancer Support joint chief medical officer Dr Rosie Loftus said: 'It is extremely worrying that cancer patients are potentially being diagnosed late because of urgent GP referrals being downgraded and it is very concerning that this could lead to GPs being reluctant to refer in the first place.
'GPs need to be supported to trust their clinical judgment when referring someone for suspected cancer. If this isn’t the case it’s a clear sign of the pressures within the NHS.'
Cancer Research UK policy manager Sara Bainbridge said: ‘If the poll is accurate, it’s very worrying. The two-week urgent referral route for suspected cancer - and ensuring GPs can send people directly for certain diagnostic tests - are crucial ways to diagnose patients earlier, when they’re more likely to survive. They are also key parts of the cancer strategy which the government and NHS have committed to delivering.
‘GPs need the support and systems in place so they can use the NICE referral guidelines, helping more patients receive a swift diagnosis and a better chance of surviving cancer. Diagnostic capacity is key and we need to see how the NHS will use the extra investment that has already been pledged.’
An NHS England spokeswoman said: ‘We expect providers to abide by NICE referral guidelines to ensure patients are cared for swiftly and in line with evidence based practice. The number of patients referred to hospital for urgent cancer checks has increased by over 600,000 over the past five years, and we’re acting on the recommendations of the Independent Taskforce for Cancer by introducing new models and more capacity for diagnosis. We’ll also be introducing a four week wait standard from referral to diagnosis for all cancers to address any variations across the country.’
GPs who responded to the poll reported some hospitals breaching the two-week wait target, and others taking desperate measures to avoid doing so.
One GP said: ‘Formally asked by a department to send referrals which fulfil criteria as standard referrals with assurance patients will still be seen promptly to ease pressure on specific two-week wait clinic.’
One said a hospital had denied receiving faxed referral letters after breaching the two-week wait. Others reported cancer referrals being downgraded because patients did not fit certain criteria, although the GP deemed risk to be high.
Although some respondents reported that downgrades had occured after discussion with hospital specialists, others said they had not been consulted over decisions to move cases off the two-week pathway.
Consultants have recently demanded a 'root and branch' overhaul of the two-week GP cancer referral system, warning that hospitals are being overwhelmed.