Cancer services have received a boost, following new health secretary Alan Milburn's 'three Cs' pledge. But a report questions whether 'open access' arrangements actually lead to quicker treatment, writes Barbara Millar

Some 17,000 women referred urgently by their GP to a breast cancer specialist were able to see a consultant within 14 days during the first three months of the government's 'two-week pledge', according to Department of Health figures.

The pledge is part of a government drive to target the 'three Cs' of cancer, coronary heart disease and cigarettes - but is it really the best way forward?

A report published this week by Warwick Business School's centre for health services studies says there is no clear evidence that such 'open access' arrangements are a good model for cancer diagnosis.

And it reveals that some specialty services in a few trusts specifically exclude open access, either because consultants 'did not agree with it' or because it had been tried and the system had become overloaded.

Health secretary Alan Milburn's pledge to focus in future on the 'three Cs' came within days of his return to the DoH, and just after prime minister Tony Blair promised£6m to speed up cancer diagnosis services.

The new money is intended to extend the two-week guarantee to cover more people and offer more onestop clinics allowing diagnostic tests to be carried out in a single visit with results available the same day.

But the Warwick report, by senior research fellow Carol Davies, and based on a survey of 42 trusts offering some form of open access for at least one form of cancer, says there are both advantages and disadvantages to such an approach.

The main advantage for patients is that waiting time for a diagnosis may be reduced, making earlier intervention possible. But, says the report, there is no evidence that cutting the time from consultation to results does lead to earlier intervention.

There is also an 'obvious advantage' to the patient in carrying out all investigations at one visit, and there is evidence that 'fast-track' patients appreciate the speed of response and suffer no more anxiety than those seen in conventional outpatients' clinics.

But, the report points out, there are disadvantages and risks to some patients who, because their GP may wish specifically to exclude cancer when the diagnosis is in doubt, undergo unnecessary diagnostic investigations.

The advantage of the system for trusts includes being seen to be responsive to patient and GP need in reducing unnecessary delay, the report says.

But such a system can become overloaded and unable to respond quickly enough - effectively ceasing to function as a rapid response service - while boundaries between rapid access and screening may become blurred.

The report also argues that while patients see the reduced anxiety time as important and the cost for each individual is small (see box), the cost to the NHS as a whole is high, especially if referral numbers are rising.

Evidence from the US suggests that demand for open access may exceed resources and services may need to be restricted as long as GPs can respond to long outpatient waiting times by using open access referrals instead.

Research shows that if waiting times are similar for both routes, fewer referrals - 36 per cent compared with 90 per cent - are made via open access.

'There is no real evidence that open access is a good model, ' says Ms Davies. 'Referral and assessment may be done more quickly but there are still delays in the system if the patient needs a treatment intervention.

'Any days saved are up to the point of diagnosis and, if you are diagnosing more people, you are putting a strain on the rest of the system.'

Open access in itself also does not guarantee people with cancer are being diagnosed earlier, she adds.

'You have to rely on patients presenting to their GP at an earlier stage. They need to seek medical help as soon as there is any sort of a problem.'

Gill Oliver, director of patient services at Clatterbridge Centre for Oncology, agrees that the system could potentially be overloaded.

'You need a validated system at primary care level so that GPs are aware of who needs to be referred early for a potential cancer diagnosis and to guarantee that those who go through open access then get early treatment, ' she says.

Nine sites taking part in a cancer collaborative project will be looking at how to ease the known bottlenecks in the system, including those in primary care, Ms Oliver adds.

And she says she has never come across a consultant who refuses to operate open access.

She also believes that, even if unnecessary investigations are a possibility, most patients 'who have been referred because they meet the criteria for open access to cancer diagnosis services', would be pleased to undergo them 'for their own peace of mind'.

Time is of the essence: what the survey found

Carol Davies' survey was based on earlier work looking at open access at five clinics in one West Midlands teaching hospital.

This study found that, compared with a conventional outpatient clinic, open access could 'save a number of days, some of which were significant, at a reasonable cost of£5 or less per day saved'.

The extended study looked at information from 25 trusts in the West Midlands and 17 from elsewhere in England and Wales which offered open access for the diagnosis of a range of cancers including upper and lower gastrointestinal tract, bladder, prostate/testicular, ovarian/cervical, breast and skin.

A few trusts had operated open access for as long as 10 years but most had begun in the past three years.

There was wide variation in the definition of open access, ranging from allowing GPs to make telephone bookings for a diagnostic appointment without prior outpatient appointment, or direct GP booking of slots in conventional outpatient clinics, to selection by consultant of urgent cases from GP referral letters.

General Practitioner Open Access to Diagnostic Services for Cancer. Carol Davies, No 319.

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