GPs face 'too many barriers' to diagnostic tests for cancer

GPs say access to cancer tests and handling of urgent cancer referrals is hugely variable across the country. GPonline looks at responses to our latest opinion poll.

In 2015, an independent taskforce set up as part of NHS England's Five Year Forward View recommended that GPs should have direct access to a range of cancer tests. Three years on, our latest survey shows that most GPs have access to blood tests, ultrasound and chest X-ray - but only around half have direct access to MRI, CT or endoscopy.

Comments from GPs responding to the poll show that in some areas access to scans is being withdrawn, rather than increased. In other areas, however, GPs say they are happy with the access they have.

The picture is similarly mixed when it comes to referrals on the two-week pathway for cancer - with GPs in some areas reporting that referrals are being blocked, or that diagnosis remains slow. Again, in other areas GPs report that the system seems to work well.

Below, GPonline picks out a selection of comments that reveal how GPs' experiences vary from area to area, and how views can diverge on the right approach to cancer care.

Why do GPs want direct access to cancer scans?

'We would prevent a significant number of outpatient referrals if we had direct access to MRIs,' said one GP. Another said: 'I feel we could cut down on a lot of admin time and secondary care time if we were allowed access to MRI/CT.'

One respondent said: 'GPs should have access to more diagnostics. We are not fools and better access would speed diagnosis of patients and save money wasted in outpatient clinics.'

Barriers to diagnostic tests deny GPs a key tool to narrow down causes of illness, one doctor added. 'CT and MRI scanning can be useful to GPs in certain scenarios - e.g. weight loss of unknown source when a specialist cannot be selected.'

Others, however, are more wary of wider access to scans.

'Personally, I do not want access to MRI/CT as the interpretation can be too subtle,' said one GP. 'If someone needs such a test then I believe they need specialist care. One of my problems with two-week wait pathways is that if they exclude cancer they then discharge the patient, and we still have the original problem and still no diagnosis or management plan.'

Another GP called direct access to scans was not a panacea. 'Test access is a mixed blessing. We can get direct CT/MRI head but nil else. We used to have direct MRI access for a lot more and it wasn't helpful - patients cottoned on and relentlessly pressured/bullied GPs for scans, most of which didn't reveal anything that helped the problem.'

What do GPs say about barriers to cancer tests?

A number of respondents reported that direct access to some tests is being reduced - with withdrawal of access to MRI the most common issue highlighted.

One GP warned that 'reducing GP access to investigations is short-sighted and dangerous as a money saving activity'.

In some cases, however, GPs acknowledged that part of the problem with widening access was a basic lack of capacity. 'Access is atrocious but I suspect there are not enough radiology staff to provide full open access,' one GP wrote.

However, one respondent highlighted how reduced direct access to scans had a profoundly limiting impact on GPs' ability to offer patients the best care. 'Our local hospital has recently decided to bounce a lot of ultrasound and MRI requests from GPs because they cannot manage the workload, without consulting any GPs,' the respondent said.

'Their suggestion is that we refer patients instead, even though that is not always appropriate. Case in point, if female patient presents with pelvic pain, the cause may not be gynaecological, it may be related to their gut, a simple USS could help distinguish these two, but we are asked to refer to gynaecology instead.'

One respondent to the poll said that access should simply be standardised across England so that GPs knew what tools were available to them everywhere. 'The access to MRI should have a national standard - it varies widely with different CCGs.'

Are referrals on the two-week pathway working?

Many GPs responding to the poll said that referrals on the two-week cancer pathway were effective - although in some cases they warned that this appeared to have left patients outside this mechanism waiting longer.

Others however, reported problems. 'My main concern is that patients referred under the two-week wait pathway are not always seen within two weeks and it takes a long time for us to receive the results of the clinic appointment.'

Another said: 'We can do two-week wait referrals but some patients wait another five months for confirmed diagnosis, this is unacceptable delay.'

One GPs said: 'Two-week referrals are now so commonplace that consultants feel overwhelmed. Some of these are purely for medico-legal reasons rather than concern re the diagnosis. Honest mistakes are no longer accepted by the GMC. Our two-week wait referrals often get seen outside the two-week limit.'

One GP said although urgent cancer referrals were not rejected outright, some patients were offered scans rather than rapid access to consultants. 'It would be far better if we had access to CT/MRI in our area - neurology is at breaking point. Two-week referrals are not declined but consultant will call and say cannot see patient within two weeks but will organise urgent CT/MRI.'

GPs also have to challenge hospitals where referrals are blocked. 'Radiology starting to bounce back inappropriately which means we have to call and discuss - extra workload for us.'

Are cancer diagnoses being missed?

Our poll found that nearly half of GPs have had an urgent referral blocked, and that one in four had seen a referral blocked for a patient who later turned out to have cancer. One GP said: 'A child with suspected lymphoma was referred to a paediatrician but downgraded and I still kept following up every six months. Eight months ago, I noted a slight deviation in FBC and re-referred to consultant. Child is having chemo in a London hospital for advanced lymphoma.'

Another wrote: 'Neurology referral bounced back when he indeed had cancer. In the end I wrote to the consultant direct and the patient was seen and diagnosed.'

How does the situation vary across the UK?

A GP who moved from England to Scotland reported better access to support from hospital departments. 'I have found it much easier to access secondary care in my current role in Scotland compared to when I worked in England.'

One GP in Wales described serious concerns: 'Compared with England, the system in Wales puts patients' life at risk. Consultants bounce back cases that don't match the NICE criteria and their own criteria to the letter. This has resulted in several mishaps.

'I believe that in England two-week cancer referrals bypass the referral management teams. This is more appropriate because the criteria don't always fit exactly, but the GP knowledge of their patient is more valuable.'

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