Why GPs need better access to diagnostic cancer scans

GPs across England are being denied access to cancer scans for their patients. David Millett reports on the potential risks to patients and the growing pressure this places on the NHS.

MRI scans showing brain tumours: many CCGs in England are denying GPs direct access (SPL)

CCG-imposed restrictions on access to diagnostic cancer scans are disempowering GPs and ultimately putting patient health at risk, leading GPs have warned.

As many as half of GPs across the country are being denied direct access to basic diagnostics to identify cancer, worrying figures uncovered by a GP investigation reveal.

The government's 2011 policy statement, Improving Outcomes: A Strategy for Cancer, made fledgling CCGs responsible for commissioning GP direct access to four major diagnostic tools - chest X-rays for suspected lung cancer, non-obstetric ultrasound for ovarian cancer, flexible sigmoidoscopy for colon cancer and MRIs for brain cancer.

GP revealed at the time that some PCTs were scrapping direct access despite this directive, in a bid to cut costs.

Access not improved

Nearly four years on, it seems attitudes and access to tests have failed to improve.

Responses from 182 CCGs in England to a GP freedom of information (FoI) request reveal that a large proportion of CCGs are preventing GPs from having direct access to diagnostics.

Less than a third (30%) commissioned direct access to all four tests, whereas almost one in four (22%) commissioned none at all, the investigation revealed.

GPC chairman Dr Chaand Nagpaul said it was 'worrying' that 'there can be such variation' across the country, in particular 'if there are restrictions on GPs being able to manage patients effectively'.

Far from alleviating pressure on diagnostic services, blocking GP direct access to the tests could see more patients referred to hospitals, which 'in itself puts added pressure on the system', Dr Nagpaul added.

But GP's FoI request revealed that many CCGs recommend that GPs divert patients through specialist services.

One in 10 CCGs said direct GP access to scans was 'specifically excluded' because 'any patient with suspected cancer should be referred through the two-week wait referral pathway'.

The two-week wait pathway is intended only as a fast-track system to provide urgent care for patients whose symptoms very strongly suggest cancer, according to NICE guidance. For most less clear, but suspected, cancer symptoms, direct GP referral would be more appropriate.

East Yorkshire GP and diagnostics expert Dr Nick Summerton said the two-week wait pathway 'would not work' if GPs were forced to flood the system with all patients suspected of having cancer.

This could culminate in a 'direct negative health impact' for patients, as a result of blocking direct access, he said. 'There's just so much going into a very narrow pipe. The pipe isn't big enough - there's not enough provision of certain diagnostics,' he added.

Wessex LMCs chief executive Dr Nigel Watson warned it was 'inevitably true' that allowing non-urgent cases to be threaded through the two-week wait pathway would leave hospitals 'struggling significantly to hit the two-week wait' target.

A wide selection of patients with suspected cancer would not be best suited to referrals, he added.

Dr Watson said: 'There are those who have obvious symptoms, where you would fast-track them.

'But there are the people with, for example, a bloated abdomen, which could be cancer of the ovary or a whole host of things. It's those patients where you don't necessarily need to refer them, but you do need quick access to diagnostics.'

NHS policy on GPs' access to cancer scans
  • The DH report, Direct Access to Diagnostic Tests for Cancer, released in 2012, advises GPs on when it is suitable to refer patients directly to diagnostic investigations, and is compiled using NICE guidance.
  • It highlights chest X-ray, non-obstetric ultrasound, flexible sigmoidoscopy and brain MRI as 'priority areas' to which GPs should have free access.
  • The report says GPs should be able to directly access the four cancer diagnostics 'in cases where the urgent GP referral for suspected cancer (the two-week urgent referral pathway) is not appropriate but a patient's symptoms still require investigation'.
  • For example, its guidance for ovarian cancer specifies that GPs should urgently refer patients via the two-week pathway 'if physical examination identifies ascites and/or a pelvic or abdominal mass'.
  • But patients who have other potential symptoms - such as abdominal pain, bloating, loss of appetite or urinary problems - may 'benefit from a direct GP referral' instead.
  • The government's 2011 strategy for cancer promised £450m over four years to help achieve earlier diagnosis 'in addition to funding increased GP access to diagnostic tests'.

Community care

General practice cannot be expected to shoulder more care from hospitals if CCGs deny them access to diagnostic tests, GPs warned.

Dr Nagpaul said the situation was 'at odds' with the government's plans to move more care into the community.

He said: 'If the government really wants an out-of-hospital strategy, it needs to make sure GPs are enabled to have access to diagnostics.'

But even in cases where direct access to the tests is being commissioned, huge strains on capacity are causing problems.

In response to a GP survey of more than 500 GPs on access to cancer diagnostics, many respondents who said they did have access to the tests slated what they described as 'ridiculous' waiting lists followed by 'unacceptable' delays in getting results.

Currently, more than 300,000 patients have been waiting over a month for their chest X-ray results to be analysed, according to a snapshot survey carried out by the Royal College of Radiologists this month.

Five CCGs, which reported that they did provide access to flexible sigmoidoscopy and MRI scans, said they had been forced to put caps on GP referrals to these services due to limitations at the level of provider radiology departments.

Unsustainable demand is crippling provider services' ability to get through the number of tests they are required to do, said Dr Summerton.

In response to GP's FoI request, only 50% of CCGs said they commissioned direct access to flexible sigmoidoscopy.

'The problem with sigmoidoscopy is you've got a screening programme which was poorly planned,' said Dr Summerton. The NHS has failed to rectify the burgeoning problems, he added.

'You've got the bowel cancer screening programme and normal gastroenterology referrals, as well as direct GP referrals, and they're all coming in to the same investigation team.

'The NHS is pouring people in at the top, but hasn't planned further down the pathway. It wants to do things for political reasons, but doesn't actually think about what it's going to do with all these positive symptoms.'

Effective testing

Dr Summerton also warned of 'another layer' to the problem. 'Even when we get access, we get access to investigations that are virtually useless,' he said.

CCGs were most likely to provide direct access to chest X-rays, he said. But chest X-rays miss one in four cases of lung cancer, potentially leading to some patients being 'falsely reassured' and delaying treatment, he added. 'Although we might have access to chest X-rays, they're useless in terms of trying to pick up early cancers, and I think that's the problem.

'Research has shown that if you're going to diagnose lung cancer early, X-ray is the wrong investigation. You need access to low-dose CT scans, and that's what we're lacking.'

GP access to CT scans in England is 'hopeless' and 'minimal', he said, but they are readily available in many other European countries. 'A CCG might allow access to imaging, but it often isn't very good imaging.'

Dr Nagpaul called for an investigation into why such large variation across the country had been allowed to develop, and to jump-start CCGs into taking action.

'We need to ensure we develop a national specification. We need consistency so patients receive equitable access to diagnostic tests and equal opportunity for early detection of cancer,' he said.

Cancer Research UK called for increased investment in diagnostics, in a September report. It warned 'cracks will begin to show' without this.

Dr Summerton said the NHS should not shy away from using private diagnostic facilities.

'Until some commissioners in the NHS get away from the idea that private is bad and public is good, we're never going to achieve anything because there is no more capacity in the NHS,' he said.

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