Improving Cancer Recognition and Referral in Primary Care

Dr Anthony Cunliffe Outlines the New Service Specifications for Primary Care Networks, and Explains How They Will Facilitate Earlier Diagnosis of Cancer

In the 2019 NHS long term plan, NHS England set out its ambition to ensure that, by 2028, 75% of people with cancer will be diagnosed at an early stage.¹ In the UK, the majority of people who are subsequently diagnosed with cancer first present with symptoms or concerns to their primary care teams; therefore, as primary care physicians, we have an essential role in ensuring that people are diagnosed as early and as quickly as possible.^2–6

However, this is challenging for GPs—every day, we consult with people who present with symptoms that may represent an underlying cancer. In the majority of these referrals, the person will not be diagnosed with cancer, and each full-time GP may only diagnose around six to eight people with cancer each year.⁷ This means that GPs have the very difficult job of identifying those patients whose symptoms need urgent investigation—while not sending patients for unnecessary tests, which cause undue worry and add to pressure on the health system. As you can imagine, this is not an easy task.

The Impact of COVID-19

The situation has been made even more exacting by the COVID-19 pandemic, which has affected the early diagnosis of cancer in several ways. Initially, we saw a significant negative impact on the number of people being referred via an urgent suspected cancer (USC) pathway, meaning that many people who would normally be investigated and either diagnosed or reassured were not entering the system.⁸ This may have been because they were reluctant to present to a health environment that they weren’t confident was safe, or due to concerns about overburdening the health service, or because changes to screening services and diagnostic pathways were impacting their ability to be seen.^8,9

Although most of the USC pathways have now recovered to above pre-pandemic referral levels, some are still lagging behind. In addition, there remains a large backlog of patients awaiting diagnosis and treatment, as well as patients who have not yet entered the system.^9–11 In its report The forgotten C? The impact of COVID-19 on cancer care  Macmillan Cancer Support estimates that 50,000 people are now missing a cancer diagnosis.¹² Another significant change during the pandemic was the move to virtual consultations. This switch brought with it a new challenge for primary care physicians, who had to ensure that the right people were still being identified for further investigation, even those whose initial contact had been virtual.

We could continue to talk about the difficulties of diagnosing cancer earlier and the likely negative effect that the COVID-19 pandemic has had on this, and about the significant progress towards diagnosing cancer earlier that has been made in recent years. However, what we need to focus on now is what we can do, as primary care teams, to contribute to the recovery of the health system and return to progressing towards the ambitions of the NHS long term plan.¹

The Primary Care Network Directed Enhanced Service

The development of primary care networks (PCNs) brought with it the introduction of the Primary Care Network Directed Enhanced Service (DES);¹³ the first service requirement, covering the early diagnosis of cancer, was introduced just before the start of the pandemic.¹⁴ There was a delay in the initial implementation of this service requirement, for obvious reasons, but it is one of only four of the original requirements of the PCN DES that PCNs are expected to have commenced and be progressing with.¹⁵ The early diagnosis of cancer service specification for 2021–2022 consists of three main elements (see Box 1).

Overlap With the Quality and Outcomes Framework

For this financial year, one of the quality improvement (QI) modules of the Quality and Outcomes Framework (QoF) is also focused on the early diagnosis of cancer.^16,17 This has caused some confusion as to the differences and similarities between the QI module on early cancer diagnosis and the DES. Essentially, they both cover very similar themes, and any work done for the QoF will be very relevant to the requirements of the PCN service specification.

The QoF QI module is only 1 year long and is focused at practice level; however, it may be useful to consider how any work completed or started within practices as part of the QoF QI module on early cancer diangosis could be built upon or fed into the work planned at PCN level for the DES. It is a perfect opportunity to spread learning and best practice between practices that may lead to changes at PCN level over a longer period of time.

How Will the Service Specification Achieve Earlier Cancer Diagnosis?

Reviewing Referral Practices for Suspected Cancer

A review of referral practices for suspected cancer is an element of both the QoF QI module on early cancer diagnosis and the PCN DES,^14,16 highlighting how important it is to ensure that referrals for people on a USC pathway are of a high quality. The element requires organisations to have systems in place to review the quality of referral practices, so that continuous improvement can be made.

There are various aspects of referral quality that a practice or PCN may decide to review, and various processes through which this can be undertaken. These include:

• education for practice teams on the criteria for USC referrals¹⁸
• audits of routes to diagnosis for people who have received a cancer diagnosis¹⁶
• learning event analysis¹⁹ of cases in which diagnosis was delayed.

Once practices or PCNs have decided what to focus on, various tools and resources are available to support them with their review (see Box 2).^20,21

In addition, GatewayC—a free educational resource for primary care healthcare professionals in England—has a module called ‘Improving the quality of your referral’ that may help PCNs and practices with this part of the DES specification (see Box 2).²²

Safety Netting

Safety netting in primary care is another element that is covered in both the QoF QI module on early cancer diagnosis and the PCN DES.^14,16 This emphasises the importance of having robust systems in place across primary care to confirm that people referred on a USC pathway or for an urgent test have been seen, and that people presenting to us with potentially concerning symptoms are followed up. Again, there are various tools and resources to support with this—including for integration into GP practice information technology systems—that can be found on the Macmillan Cancer Support website (see Box 2).²³

It is an essential part of good practice to ensure that patients have a good understanding regarding any referrals that are made, so that they appreciate what to expect, are aware of any preparation they may need to do, and know what action to take if things don’t happen as anticipated. This communication is a fundamental part of safety netting; it should be delivered verbally as part of the consultation, but it can be augmented by the use of patient information leaflets, provided either as hard copy or digitally via text or email. Useful resources to help with this are available from both Macmillan Cancer Support.²⁴

Improving Local Uptake of National Cancer Screening Programmes

Increasing the uptake of national screening programmes is one of the most important ways in which primary care can contribute to the earlier diagnosis of cancer.²⁵ Some areas of the country have very poor uptake of national cancer screening programmes—as low as 45.1% for bowel screening, 51.8% for breast screening, and 47.4% for cervical screening.²⁶

Evidence shows that GP endorsement of screening programmes can lead to an increased uptake;²⁷ therefore, practices and PCNs should be encouraged to review their screening data and look at ways in which they can encourage and assist people to participate in screening programmes. The decision to take part is down to the individual, but efforts to increase uptake can focus on ensuring that people who decline have first received the right information and had a chance to discuss their concerns.

It is important for PCNs and practices to understand their local data in order to decide where to focus their efforts when it comes to screening. One useful source is the Public Health England Fingertips database,²⁶ which shows uptake at practice or PCN level relative to other local areas or national statistics. More information on how to improve screening uptake can be found in the CRUK PCN DES Hub (see Box 2).²⁸

Establishing a Community of Practice to Support Delivery of the Requirements

One of the benefits of working together as practices within a PCN is the sharing of best practice and resources, and this is the basis of the development of a ‘community of practice’. It is likely that much of the work required may already be happening at some level within PCNs, so getting together early to review progress may be very useful in agreeing any work plans. Where practices have already had success in some of these areas, sharing how they attained it and supporting other practices to do the same is fundamental to disseminating learning and success across a bigger footprint. If challenges arise, or there is uncertainty as to what to focus on, discussing this at PCN level with a range of interested primary care healthcare professionals may help to overcome barriers and enable the practices involved to agree on priorities. Having clinical and nonclinical champions to lead on the different requirements may make the work run more smoothly, and increase the chance of successful outcomes.

Tackling Health Inequalities

Health inequalities are defined as avoidable and unjust differences in health status between groups, populations, or individuals generated by social, environmental, and economic variation within societies.²⁹ These differences can influence an individual’s risk of ill health, and affect their ability to access treatment.²⁹ Addressing these inequalities should be a fundamental consideration in everything we do as healthcare practitioners.

The QI requirements outlined in the QoF QI module on early cancer diagnosis and PCN DES provide us with an opportunity to review the prominent inequalities affecting our local populations, enabling us to ensure that these are addressed as workplans are put into place.^14,16

Working with Local Partners

Finally, although these contractual pieces of work are to be led by GPs at practice or PCN level, it is important that we work with other local partners and organisations, both to get any support available and to prevent duplication of work. All areas of England are covered by cancer alliances,³⁰ and it is likely that all alliances have work planned to support PCNs in their area with the DES. Reach out to your local alliance and find out what support is available—this may include help with identifying the right data to inform your work, educational programmes and events, and direct support from cancer lead GPs. Another great source of help is the third sector: both Macmillan Cancer Support and CRUK have created resources to help with the QoF QI module on early cancer diagnosis and the PCN DES (see Box 2).^28,31

Summary

The world of general practice is busier than ever, and GPs may feel overburdened by having to deliver pieces of work like the ones discussed in this article. However, primary care teams are fundamental to the NHS’s plans to tackle late diagnosis of cancer. Take some time to review all of the good work that may be happening already, agree priorities, share good practice between practices and PCNs, and distribute the workload between team members.

Dr Anthony Cunliffe

Macmillan National Clinical Adviser for Primary Care, Macmillan Lead Clinical Adviser and Clinical Adviser for London and Joint Clinical Chair, South East London Cancer Alliance