David Oliver: Don’t blame GPs for late cancer diagnoses

Editor

I thank Dr Crawford for his response and I think we are in broad agreement.

I have acknowledged in this and other columns that as he puts it "the NHS isn't big enough". The GP workforce numbers have been flat at best over the past decade or more at a time when the volumne and complexity of work and range of expectations have risen, community nursing and social care have been cut and the population demographic and pressure on acute hospital beds means ever more complex and unstable patients are on their caseload.

Meanwhile we have among the fewest doctors, nurses, beds and scanners per 1000 population among OECD nations and relentless pressure on hospital services. There are growing workforce gaps in secondary care too, with around 1 in 9 medical posts unfilled and currently around 40% of consultant physician posts unfilled at interview. The pressure on vital diagnostic services so relevant to cancer such as endoscopy and radiology is relentless and they would be overwhelmed if even more referrals came their way - especially those with urgent access time targets attached. There are similar pressures on specialities most likely to diagnose cancer and to refer for Oncology or surgical input. We have relatively few oncologists per 1000 population compared to many developed nations and elective surgery is struggling to meet waiting times.

In this environment and with many of those disciplines having to balance cancer work with many other clinical conditions and priorities, we absolutely cannot attribute all disparities in cancer outcomes compared to other nations to our GP gatekeeper/first consultation model.

I pointed out clearly that most patients diagnosed with cancer had in fact seen their GP and that diagnosis on emergency presentation to hospital was not the norm.

I was also careful to make the point that it wasn't the Cancer Research UK report's intention to blame GPs, but that unfortunately this was how such reports were sometimes reported in mainstream media, especially in headlines more sensationalist than details in the body of the article.

I have acknowledged in numerous pieces that our outcomes for some conditions in the NHS are mediocre by OECD or EU standards.

On reflection, I think the only major difference of emphasis I can see between Dr Crawford and me is that he seems (and forgive me if I have misunderstood) to be arguing that even the threshold of 3% positive predictive value recommended by NICE for cancer referral by GPs is perhaps too restrictive; that GPs seeing people with early, undifferentiated symptoms which might well not be cancer at all - let alone red flags for cancer - should refer urgently regardless and that we should copy some other nations where patients can bypass the GP referral process and self refer direct to a specialist of their choice.

Given that our system is already struggling for resources, staffing, availability of investigations and funding, such an approach would at the very least need strong initial evaluation looking at cost, opportunity costs for non cancer patients or other service lines, sustainability and impact before becoming the new norm. Then again, if it's good for stroke, why not make it the norm for other potentially life limiting medical conditions like heart, kidney or lung disease?

I am a geriatrician and general internal medicine physician working in acute care, Dr Crawford is an Oncologist. It would be really interesting to get a take on his suggestions from some GPs who do the referring and gatekeeping.

I am fed up with seeing GPs being bashed repeatedly in headlines and will continue to defend them vigorously

David Oliver

The public often mocks our medical care for “wrong” and “late” diagnoses.<1> But isn't using "time as a test" a tool physicians have been taught to aid our differential diagnoses? <2>

The onset of illness and disease progression could be tell-tale signs of a medical condition. When I am at hospital taking referrals, I am often thankful to the preliminary workups performed in primary care, as they help me to rule out some differentials.

Differential diagnosis means determining the most likely cause of an illness based on a list of most possible explanations. There are always chances that the most likely explanation can be wrong. If clinicians have worked long enough, they must have made a wrong differential diagnosis at least once in their career. But does it mean they are unsafe? Usually, when patient fails to improve on initial management, clinicians would consider other likely causes of the illness.

There are often derogatory implications when the media reports patient having the "wrong" or "late" diagnoses. But let us look at another scenario. A patient presents with systemic inflammatory response syndrome in an emergency department. The emergency doctors start antibiotics for query pneumosepsis and refer to internal medicine. When the medicine team perform a more thorough assessment, they suspect pulmonary embolism and order a chest computed tomography, which later confirms their suspicion. Patient eventually receives the standard treatment and is safely discharged home days later, praising the care received. But in such a scenario, should we penalise the emergency doctor for making the wrong diagnosis of pneumosepsis in a time-critical situation? Or should we mock the patient's general practitioner for missing the pulmonary embolism in the community?

These news media articles about "late" and "wrong" diagnoses serve the purpose of damaging doctor-patient trust, and do little to improve our healthcare system.

References

1. Oliver D. David Oliver: Don't blame GPs for late cancer diagnoses. BMJ. 2019;366:l4625.
2. Spence D. Bad medicine: reassurance? Br J Gen Pract. 2018;68(670):239-239.