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The LMC’s view on Cancer

Date sent: Sunday 13 July 2014

Email sent by Wessex LMCs, on Saturday, 12 Jul 2014

Read this email and consider the contents. This should count for at least and hour of CPD and if you implement any of the suggestions you should record this as a "Quality Improvement Activity" for your Appraisal.

How to improve early diagnosis and survival rates without naming and shaming GPs

I am sure many of you have reacted with some anger and much disdain about the proposals relating to naming and shaming GPs who fail to diagnose cancer. If only it were that simple!

I personally do not think naming and shaming GPs will improve early detection and survival from cancer. It will lead to increased referrals, with the fast track clinics being over whelmed and encourage GPs who are considering leaving the profession to make that decision earlier than they would have done previously.

But perhaps we should ask ourselves what could improve early diagnosis and survival rates and propose these as an alternative to the Government?

Background

A full time GP would expect to have about 10-12,000 patient contacts per year.   This would mean that on average a full time GP would expect to see about 8 -10 new cases of cancer per year or about 1 in every 1000 – 1500 contacts.

Recent reports seemed to suggest that patients were frequently missed by GPs in terms of cancer detection and often had multiple consultations before cancer was suspected. 

The facts are somewhat different from this. About 75% of cancers diagnosed, are referred after only 1 or 2 GP appointments – rather than be castigated for this, the figures are quite impressive, especially if you take into account the multiple ways each cancer can present and some with very few symptoms and signs.

However well practices perform, 25% of practices will always be in the bottom quartile of performance whatever their outcomes are. When 95% confidence levels are taken into account very few practices are outliers.

As a nation we spend less per patient that other Western nations and we have 20 – 25% fewer doctors per 100,000 population than most western countries. More doctors to improve access and the time spent with patients would almost certainly lead to earlier detection and referral for cancer.

Proposal 1 - "three strikes and you are in"

I am sure you remember being taught early in our training - the "three strikes and you're in" - the scenario of the patient presenting with the same symptom for the third time = time to think broader and deeper – i.e. might this be cancer, and do I need to do more/refer for diagnostics/an opinion...?

Proposal 2 - "Know 4 sure" campaign

The "Know 4 Sure" campaign was piloted last year locally and profiled 4 symptoms:

One or more of these symptoms are present in a significant majority of all cancers.

 

You may have read the challenging and rather unfortunate letter, from the President of the Royal College of Pathologists published in the Daily Telegraph recently. Please see below:

The Royal College of Pathologists welcomes proposals by Jeremy Hunt, the Health Secretary, to publicise persistently poor detection of new cancers by GPs.

The timely diagnosis of cancer depends on clinical suspicion backed up by efficient use of the right test.

The marked discrepancies in the use of blood tests by GPs for some cancers are described starkly in the recently published NHS Diagnostic Atlas of Variation. There is a five-fold variation in the use of the PSA test for prostate cancer and a nine-fold variation in the use of CA125 for ovarian cancer.

These tests are available across the NHS. There is no single satisfactory explanation for such variable performance, but it is not because of differences in the demographics of GPs’ patients.

Uniform and rapid communication of results of all tests from pathology labs to all users, especially GPs, requires the development of a national laboratory medicine catalogue, a list of pathology tests that have been validated for use within the NHS. The NHS funding of this is at risk.

The College has urged the Secretary of State to protect this project and it’s funding.

Dr Archie Prentice

The Royal College of Pathologists

London SW1

 

The “school report” for GPs and practices would read – doing well, but with a little more application, could do even better…

GPs are doing a great job, but we can do even better with more funding, and peer to peer support; and naming and shaming would ultimately result in a longer wait for diagnosis as waits for appointments for investigations and review would extend dramatically, not to mention the impact on the GPs who had the misfortune to be "named".

So lets not be complacent and think about the important question below?

 

What can GPs and Practices do to improve the early detection and survival rates for cancer?

If there was one answer we would have found it, so consider the following:

Practice Information

If you follow the link: Cancer toolkit 

This will take you to the National Cancer Intelligence Network, click on the Public Users then Profiles, then Profiles again. You can then select a practice or CCG profile and it will allow you to identify your practice.

You can look at data from 2010, 2011, 2012 or 2013 and compare your practice to the CCG average or national average.

This data will not give you answers but will raise a number of questions that only the clinicians in the practice can answer.

 

Proposal 3

Consider inviting your local Macmillan GP to your practice to discuss the practice report with you.

You can access the Macmillan GPs the Wessex Strategic Clinical Network via sallyrickard1@nhs.net 

 

Practice vs. Personal Audit

When GPs receive a letter that informing them one of their patients has cancer, the immediate reaction is to look back at the notes and follow the sequence of events that led to the referral and see if in retrospect things could have been done better.

Occasionally if appropriate and there are lessons to be learnt these patients will discuss cases in a practice’s “significant event” meeting.

 

Proposal 4 

Consider reviewing each new cancer presentation to see what lessons can be learnt as an individual and then share these at your practice significant event meeting.

 

 

Macmillan Primary Care Audit Tool

The key themes from this are:

We are taught to explore patient’s fears and understanding and not assume them; in this situation this is particularly relevant.

 

Proposal 5

If a person DNAs in your surgery look at their notes and see if it is a planned follow up and therefore may be important. If you have concerns you may need to contact the patient.

 

We are generally happy with the 2WW referral system and also when a patient can wait with no significant detriment to their health.

An urgent referral is frequently used when the GP cannot justify a 2WW and believes a routine referral would have a significant impact on the patient’s health.  Writing a referral and marking it urgent does not absolve the GP of responsibility.

Ask the patient to contact you or come back for review in an appropriate timescale if they have not heard from the clinic.

 

This could be related to overuse but also underuse.

 

This one of the major problems identified in complaints and delayed treatments.  This is something we all need to improve.

 

Consider completing the BMJ Learning Module:

Supporting people with cancer in primary care: in association with Macmillan Cancer Support

 

Improve safety netting to ensure all patients referred under the two-week rule are seen

  1. A surprising number of 2WW referral patients who fail to attend/postpone their appointment (estimated at 20%)
  2. Make sure the patient understands that referral is to exclude the possibility of cancer.
  3. Have a system to follow up/flag up any DNAs at 2WW appointments (similar to screening DNAs).
  4. It may be regarded, as good practice to ask patient to have GP follow up 4 weeks after referral to WW, as by then the diagnosis is likely to have been met.
  5. All practices should consider using the   Two-week rule patient information leaflet. 

 

Some key issues: -

Safety Netting – these are suggestions taken from the Macmillan GP leads

 

We are very fortunate to have Dr Richard Roope who is a GP in Hampshire, the GP Macmillan Cancer Lead for the Region, is a member of the Cancer Network and is now the RCGP/Cancer Research UK, Clinical Lead for Cancer.

 

The LMC has been working with Richard and Mr Matt Hayes The Chair of the Local Cancer Network and a Consultant Urologist at University Hospital Southampton.

 

Summary of proposals

1. "Three strickes and you are in"

A patient presenting with the same symptom for the third time = time to think broader and deeper – i.e. might this be cancer, and do I need to do more/refer for diagnostics/an opinion...?

 

2. "Know 4 sure" campaign

One or more of these symptoms are present in a significant majority of all cancers.

 

3. Consider inviting your local Macmillan GP to your practice to discuss the practice report with you.

You can access the Macmillan GPs the Wessex Strategic Clinical Network via sallyrickard1@nhs.net 

 

4.  Consider reviewing each new cancer presentation to see what lessons can be learnt as an individual and then share these at your practice significant event meeting.

 

5.  If a person DNAs in your surgery look at their notes and see if it is a planned follow up and therefore may be important. If you have concerns you may need to contact the patient.

Further Support can be found at Wessex Cancer Trust: http://wessexcancer.org.uk/

 

I hope this is helpful.

 

Best wishes

Nigel

 

Dr Nigel Watson

Chief Executive

Wessex LMCs

Churchill House, 122-124 Hursley Rd

Chandler's Ford, Eastleigh

Hants. SO53 1JB (Registered Office)

Tel: 02380253874

Mobile: 07825173326

www.wessexlmcs.com

 

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