The BBC reports All GPs to receive direct access to cancer tests. Superficially one might think this is a good thing but is it not just solving one problem and creating another? It feels like the squeezed balloon problem. One bit gets smaller as another gets bigger.
By cancer tests the headline refers radiological imaging. That might be CT or MRI scans of varying complexity.
The BBC quotes Amanda Pritchard, NHS Chief Executive, as saying she “hopes the new initiative will lead to tens of thousands of cancer cases every year being detected sooner”. I predict it will lead to a massive increase in scans and with that, because there aren’t enough scanning machines or staff to run them this will result in even greater delays in diagnosis.
As well as delays lots of unnecessary (wrong) and expensive scans will be done and lots of scans needing repeating, because of ‘incidentalomas’, abnormalities that are almost certainly harmless, but need monitoring to be sure. You can imagine the anxiety these cause some patients.
Historically CT and MRI scans were the preserve of specialists. When they first became available in the NHS they were expensive and their availability was limited. As the decades have gone by and junior doctors in hospitals have had experience at ordering and reviewing the images they have taken that confidence out into general practice. The availability of these tests has improved too. In some places it became commonplace for GPs to order these tests.
The BBC quotes Dr Martin Marshall, chairman of the Royal College of General Practitioners as saying
“The college has long been calling for GPs to have better access to diagnostic testing in the community,”. Actually, I’m not sure that’s so true. Whilst there may be some GPs who like to wow their patient with their ability to get them squished into an expensive scanner, many prefer not to undertake tests that are rightly the preserve of specialists. GPs may be seeing patients who potentially have cancer, that doesn’t mean they should be diagnosing it, after all, they’re not usually the ones who are going to treat it, and the first scan rarely enables decisions to be made on definitive treatment. Specialists do all that, but their clinics may before long be even more clogged up with minor scan abnormalities.
Dr Marshall may be referring to somewhat simpler testing – phlebotomy, new tests for asthma, for sleep apnoea, for palpitations and poor circulation. All these simple things have become hard to access in the post pandemic NHS and should be readily available in the community.
The ability for a GP to order a test should not be confused with good medicine, and with an efficient NHS. There have been many a time that GP colleagues have admitted not known what do with a patient and considered a scan might be the best next step. It’s a good way of closing a consultation and crikey that option is needed quite often when GP appointments were limited to ten minutes. A scan carries much more kudos than ‘wait and see’ or ‘here’s a prescription’, or ‘let’s get some blood tests’.
My scan requests are limited to ultrasounds. These became quite cheap with private providers filling the capacity gap that existed 10-20 years ago. That also meant they could be done in two weeks or so. That, in NHS terms is lightning fast. In other health systems GP have ultrasound machines in their buildings and have the expertise or colleagues who can do the test within two hours, not weeks! Currently, it is not possible to even get an ultrasound in two weeks. Six is the national target, and where is that being achieved? Anywhere?
I’ve never got into ordering CT or MRIs much though because I worry about using what I was trained, admittedly donkeys’ years ago, to regard as a relatively scarce resource unnecessarily. I know of specialist colleagues whose hearts sink when they read referral letters that contain the results of such scans. They sink because the wrong scan has been ordered and no-one has had the time to consider this before it was done. The wrong scan just wastes NHS time and money and can delay diagnosis and access to treatment but it’s not quick or easy to decide this at the time of booking the appointment. It’s quicker just to do it! So let’s not forget the inconvenience for patients and their families, and the environmental costs too when it’s not the right scan. These costs sure add up. If a good proportion of a radiology department’s scanning is unnecessary just think how much it costs.
When I started working in NHS commissioning, in a health system that was heavily in debt, it was felt that cutting back on activity by 5% or so would help the system get back into financial balance. There was little doubt in many doctor’s minds that there was at least 5% of waste across the board and that size of efficiency saving was achievable.
From there flowed huge initiatives to cut back on the unhelpful ordering of tests by GPs that added little to patient care, cost money and other delayed other patients’ treatments. Our local radiology department saw a significant drop in demand from GPs, and (pre-Covid) they were able to reduce the waiting time for patients that specialists had seen and who it was thought more likely to have cancer. It also meant the right type of scan was done from the beginning, by the specialist, who in those days patients could get in to see.
GPs were still able to order scans when they’d consulted with specialists, usually via the national Advice and Guidance system, a process of letter exchange with local specialists, that gives GPs a steer, within 48 hours normally, on how to manage a patient. Part of that advice might be ‘get a scan’ and the radiology department would willingly book the patient in. That does create a little delay and some GPs objected to losing their autonomy. In a system as strained as the NHS has been, that dent to egos was a small price to pay for improving efficiency, and ultimately patient care.
A problem of GPs ordering such tests though is the mantra in the NHS, whoever orders the test deals with the result. Unfortunately, complex scans generate complex results. A large number of incidentalomas are found – harmless abnormalities that scare the pants off patients – and frequently then lead to repeat scans to monitor for change which scares them more.
The specialist language of a radiology report is often beyond that of most GPs who then have to go back to other specialists for a translation or advice on ‘What next?’. That doesn’t engender confidence in GPs but believe me it’s beyond the remit of most GPs to become versed in all this detail. For both of these reasons I much preferred the specialists ordering the scans and then dealing with the result. They can readily advise the patient it’s all normal, and send them back to me if their symptoms persist, or it isn’t, and arrange to see them. There’s not much point in GPs being go-betweens.
The headline looks good. It might look as if it will help patients but I doubt it. I predict radiology departments will be overwhelmed. It might ‘work’ if there’s a shed-load of money going into private providers though I suspect they’ll have to lure staff away from the NHS to run a service. I think it will cost a fortune, wherever it’s done and I don’t believe UK cancer survival rates will improve as a result. A lot of to and fro for clinicians who are already exhausted will ensue. It doesn’t entice me to stay working in general practice.
ShaunOConnell.com 