Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Improving cancer waiting times now with the Collaborative
- David Levy (17 October 2001)
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Two week cancer referrals
- Paddy O'Reilly (21 October 2001)
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patients face significant waits for investigations
- Peter Sykes (26 November 2001)
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The power of partnership
- Mitzi AJ Blennerhassett (31 May 2002)
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David Levy, Consultant Oncologist Weston Park Hospital Sheffield
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Editor Oliver, in his letter1, rightly comments that the two-week rule for cancer referrals is only the first part of the patient journey and that “all parts of the care pathway need speeding up”. The two week rule for referral is part of the National Cancer Plan which sets targets of the time from urgent referral to first definitive treatment being no more than 62 days for all cancers by 2005. This is an ambitious target and the Cancer Services Collaborative (CSC) is the mechanism by which the Department of Health seeks to implement this part of the National Cancer Plan ². The CSC is linked to the booked admissions programme and seeks to ensure that the patient journey is booked at three parts of the journey (to first outpatient appointment, first diagnostic test and first definitive treatment). It involves mapping out the current and the ideal patient journey with all members of the multidisciplinary team and others involved in that journey (e.g. out patient clerks, secretaries) The CSC is initially dealing with five common cancers, breast, lung, colorectal, prostate and ovary. It will roll out across cancer networks early in 2002 and to other tumour types later in 2002. In cancer networks some changes that are found to improve a patient's journey in one cancer unit/centre will be considered for implementation in other parts of the network. With a collaborative approach it is expected such changes may also be used in other networks. Other measures of outcome included in monthly reports to region and the centre are time from referral to treatment, patient satisfaction and the percentage of patients, with a newly diagnosed cancer, who are discussed in a multidisciplinary Team meeting. Issues around capacity will arise as well as the need for workforce planning. It is envisaged that where gaps appear, those solutions that require investment will be considered priorities by the new commissioning bodies. However it is expected with more flexible working across cancer networks, not all solutions will require additional resource. Although the CSC has been running since April 2001, its existence has been poorly publicised. It is a process that will change the way many doctors work, both within Secondary and Primary Care 1. Oliver M.D. All stages of care pathway need speeding up BMJ 2001; 323:854 (13th October.) 2. The National Cancer Plan Dept of Health September 2000 No competing interests |
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Paddy O'Reilly, Consultant Urological Surgeon Stepping Hill Hospital, Stockport
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Dear Sir, We write to agree with the sentiments expressed by Simon Thomas and Neil Burnet (BMJ 13th October 2001). We are auditing the 2 week cancer referrals to one urologist (PO'R). Referrals received were July (14), August (9), and September (15). If routine new patient clinics need to be top-sliced to accommodate these, it would mean 3-4 less routine cases weekly. The waiting time for these clinics has already risen from 10 weeks to 18 weeks. The problem is compounded by inappropriate referrals. In most cases this is not the fault of the general practitioners, who are not trained urologists (although the 4 year hydrocele, and PSA of 6.2 in a man of 75 are open to question!). However, of 14 scrotal swellings, 13 were clearly epididymal, and some in elderly men, with only one obvious testis cancer. Marginally raised PSAs in men over 75 do not need to be seen in 2 weeks. Patients with haematuria might be better seen in a comprehensive one-stop clinic (including cystoscopy and renal ultrasound) in 3-4 weeks, rather than "seen" in a normal clinic in 2 weeks. The question is whether patient pressure, some degree of defensive medicine, and lack of urological training amongst GPs is pushing patients into the 2-week category when they do not need to be there. It may be that the consultant himself will have to assume responsibility for interpreting the GP's referral letter and categorisiing the patient, if the whole system is not to be made untenable. The motivation behind the 2 week referral plan was clearly a good one; in practice some good clinical sense and further discussions between primary and secondary care and the Department of Health are required to make it work effectively. Gim Ong, SHO in Urology Paddy O'Reilly, Consultant Urological Surgeon. |
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Peter Sykes, Consultant Surgeon Trafford general Hospital, Manchester M41 5SL
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Patients face significant waits for investigations Editor- In a recent letter, Oliver1 raised the point that all stages of the cancer care pathway need speeding up, not just the time taken to see urgent “two week rule” referrals2. We are becoming increasingly concerned about the long delays many patients experience whilst they wait for investigations needed before the most appropriate treatment can be decided. The initial delay to see a hospital consultant, and the time spent on a waiting list for treatment, are nationally audited and familiar to patients but the “third” wait for investigations is rarely acknowledged. We recently carried out a postal survey of hospital departments in the Northwest of England and found disturbingly long waits for commonly requested investigations. Over a third of the endoscopy and radiology departments that we contacted quoted waits of over two weeks for urgent tests where there was a high suspicion of malignancy. 8% of such patients waited over 4 weeks. Waiting times for tests where malignancy was thought unlikely but needed to be excluded were longer, with a median wait of between 4 weeks and 2 months, and some waits over 8 months. Patients waiting for investigations for benign disease with mild-moderate symptoms fared even worse, with a median wait of over 2 months, and again some waiting over 8 months. Waiting times for non-urgent (routine) magnetic resonance imaging was over 11 months in one hospital. In many cases the investigations are essential before treatment can proceed and clinicians have no choice but to delay until the results of the investigations are known. In other cases, however, the investigations are helpful rather than essential. In these instances the clinician will face the dilemma of whether to proceed to treatment without the investigations, to order an alternative test which could be performed more quickly but would give less helpful results, or to delay treatment until the investigation of his or her choice is done. We conclude that the wait for investigations is often significant and that limited resources might be more effective if spent reducing waiting times for investigations, rather than in implementing the “two week rule”. It might be useful to create a “waiting for investigation index” akin to the cost of living index to measure the performance of individual trusts and then to aggregate this “third wait” into official waiting times for treatments. Yours sincerely Miss Vanessa Pope
Mr P.A. Sykes
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Mitzi AJ Blennerhassett, Secretary, Cancer Concern Self Help and Support Group Home, N Yorkshire
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Until now, the level of women referred as 'non-urgent' - even before the 2 week rule - has been hidden. It is something I have campaigned about for years and later experienced myself; despite indicators such as discrete lump in the upper, outer quadrant, a previous history of cancer, age 57 and taking HRT for 10 years, my GP was only prompted to refer me after assessment at a cytology clinic -and still took another two weeks before he wrote the letter, resulting in a 5 month delay. Breast clinics need to reflect need, not deal with 'guesstimations'. All women with breast problems which could possibly be cancer need to be seen within two weeks. Is it right to lay the burden of correct assessment on GPs, even with guidelines to assist, if triple assessment is not always definitive? Patient and carer input can only nibble at change, but with high levels of user input, Networks and Collaboratives spreading good practice can effect change. Genuine partnership between users and professionals can break down attitudes (1). Together we can strengthen the lobbying voice which is needed in order to obtain realistic resources so that you can have improved job satisfaction and we (and you - as patients!) get timely and appropriate treatment. (1) Baker M. 2002. Modernising Cancer Services. Radcliffe Medical Press, Abingdon. |
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