Rapid diagnostic centres should help bypass NHS gatekeepers

The former chief inspector of hospitals and national cancer director has said such centres would accelerate diagnosis and allow GPs to rapidly refer people with “non-specific symptoms which would otherwise not fit existing two-week wait pathways”.

While their primary aim is diagnosing more cancers sooner, they “would also facilitate earlier diagnosis of other significant conditions,” the review written for the Health Foundation think tank said.

NHS England announced this April that it would trial 10 multidisciplinary diagnostic centres in hospitals around England. Five are in London, two are in Manchester and one is in each of Leeds, Oxford, and Airedale, in the north west of England.

A progress report found the “MDC-based pathways are providing rapid diagnoses for patients within planned routes of care” and have “recorded high levels of satisfaction amongst patients themselves”.

The Health Foundation review looked at cancer services in England between 1995 and 2015. It welcomed the new government policy to increase the proportion of patients diagnosed at an early stage from 50 per cent to 75 per cent by 2028. But it said it will be “challenging”, especially because early state diagnosis has remained at 52 per cent from 2015 to 2017. 

The report also noted improved data collection, which “demonstrated the magnitude of late diagnosis, and its impacts on survival”, had driven goals to increase early diagnosis. 

One analysis, published in 2010, showed nearly a quarter of patients were having their cancer diagnosed when they presented as an emergency. This came as a shock, the review said, as did its link to poor survival rates after one year for some cancers.

The growing understanding of the importance of early diagnosis has led to “something of a policy crossroads around the role of primary care,” the review said. There are arguments to empower GPs to do more diagnostic work but also “a growing belief” that GPs’ “gatekeeping function” must be side-stepped.

The review said, in practice, getting more patients diagnosed earlier may require GPs to do more diagnostic work, such as using the new faecal immunochemical test for colon cancer in primary care on people with “non-alarming bowel symptoms”, as well as finding ways to speed up referral or “bypass general practice”.

However, encouraging doctors to refer more patients into diagnostic services “can also be met with resistance from commissioners under pressure to limit hospital referrals” and a shortage of capacity in diagnostic services in secondary care.

“The access to diagnostics in this country is inadequate,” Professor Sir Mike said at a launch event for the review. “The total number of CT scans done in this country, whether it’s looking for cancer or other things, are way below those in other countries.

“We’ve got to make things easier for the patient to get the care that they need and to get investigated if that’s appropriate,” he said.

Professor Sir Mike also told HSJ this would require getting “all the key stakeholders”, including GPs, radiologists, radiographers, endoscopists, “really working together and asking ”what are the models we can develop?… Just saying ‘we can do nothing’ is not good enough.”

Also speaking at the event, Rebecca Fisher, a GP and co-author of the study, pointed to “pressure at the moment on services as a whole, across the system”. She said it was important to view the diagnosis process as a “pipeline”.

“[It starts] with patients being able to identify symptoms that are possibly concerning. Then getting in to see [GPs] in the first place, acknowledging that there are problems there. But then we have to support GPs to be able to refer patients,” Dr Fisher explained.

“I would challenge you to find a GP who hasn’t had a referral, even one on the urgent two-week wait pathways, rejected,” she said. “Everyone is under pressure, there is very limited capacity, particularlarly in some areas, endoscopy is one of them… and you do get referrals back saying: ‘Actually we can’t see this one on the two-week wait, we’re going to have to put them on a non-urgent pathway.’”