NICE lowers cancer referral threshold for GPs in guidance overhaul

GPs will refer more patients for cancer tests under revamped NICE guidance that lowers the threshold for referrals and calls for a significant expansion of direct access to diagnostic tests in primary care.

Referral: NICE has lowered threshold for GP referral to 3% (Photo: JH Lancy)
Referral: NICE has lowered threshold for GP referral to 3% (Photo: JH Lancy)

NICE has lowered the referral threshold for possible cancer symptoms in its updated guidance, meaning that GPs should now refer patients who have a 3% chance of having cancer for further testing, compared to 5% previously.

The guidance forms part of a drive for early diagnosis, which NICE believes will help boost cancer survival rates in the UK.

Professor Willie Hamilton, a GP in Exeter and a professor of primary care diagnostics who helped develop the guidance, said: ‘[The guideline] will open the door for smarter testing so that people with cancer will receive their diagnosis much earlier. There is no doubt in my mind that this guideline will help to save lives.’

Symptom-based guidance

The guidance lists symptoms that may indicate that the patient has cancer, links them to specific cancer types, and recommends timeframes for diagnostic tests.

It also introduces ‘safety netting’ recommendations, where GPs should actively monitor patients with symptoms that do not meet the 3% threshold.

Dr Steve Hajioff, chair of the expert group who developed the guideline, said: ‘Not only will it speed up the process of referral, enabling faster diagnosis, but its recommendations to monitor people with less severe signs and symptoms will mean fewer cancers are missed.’

The guidance will also help patients to identify which symptoms are worrying, Dr Hajioff said.

Direct access to tests

NICE recommends that CCGs should expand direct-access schemes so that GPs have more diagnostic tests available to them.

‘This guidance brings some hospital tests under the wing of GPs,’ said Professor Hamilton. ‘Brain scans, abdominal CT scans, some gastroscopies - GPs may now order them directly.’

Dr Hajioff said that direct-access tests are already in place in some areas of the country, but he hopes commissioners will standardise access to diagnostic tests.

The change in guidance will increase demand on diagnostic services, said a costing statement on implementation of the guidance. Commissioners ‘may need to consider alternative models of care to create additional capacity for diagnostic tests’, the report said.

Best interests

The guidance has ‘modest’ cost implications for primary care, he said. Initially, specialists may see a rise in referrals, but as direct access testing becomes more widely available, the ‘overall cost will be smaller than expected and the benefits greater than expected’.

Professor Hamilton told GPOnline that the guidance included a ‘margin of error’ which would allow GPs to follow their instincts in exceptional cases.

‘We have added a recommendation saying that GPs should override the guidance if it’s in the patient’s best interests – if they have a gut feeling that something isn’t right and it could be cancer,’ he said.

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