Direct access to imaging for cancer from primary care
BMJ 2023; 380 doi: https://doi.org/10.1136/bmj-2023-074766 (Published 09 February 2023) Cite this as: BMJ 2023;380:e074766Linked Analysis
Early diagnosis of cancer: systems approach to support clinicians in primary care
- Samuel W D Merriel, NIHR academic clinical lecturer1,
- Igor Francetic, research fellow1,
- Peter Buttle, patient representative
- Correspondence to: S W D Merriel Samuel.merriel{at}manchester.ac.uk
In November 2022 the NHS chief executive, Amanda Pritchard, announced that all general practitioners in England will have direct access to diagnostic imaging for patients with concerning symptoms that fall outside the criteria for urgent referral of patients with suspected cancer.1 The plans build on the rollout of 160 community diagnostic centres, scheduled for completion by 2025,2 which provide more local imaging services outside acute hospitals. Exactly what constitutes “concerning symptoms” has not yet been defined,3 and investigating and diagnosing cancer in patients with non-specific symptoms is challenging, as discussed by Black and colleagues in a linked article (doi:10.1136/bmj-2022-071225).4
The policy announced by NHS England could help reduce longstanding inequalities in GP access to diagnostic imaging that currently exist between NHS regions.5 For example, the proportion of general practices with access to magnetic resonance imaging (MRI) varies from 20% to 85% among regions. Direct access to imaging by GPs also has the potential to increase early diagnosis of cancer and other diseases.6 Available evidence, although limited, suggests that direct access from primary care shortens time to imaging and is associated with higher patient and GP satisfaction.7 Increasing direct access could also help reduce differences in cancer diagnoses rates resulting from the variable propensity of GPs to use urgent referral pathways for suspected cancer.8
The concept of increasing access to diagnostic imaging in primary care has been cautiously welcomed by GPs, although GP leaders underline the need to resolve diagnostic workforce shortages and to ensure integration with current systems to increase the likelihood of success.9 Shifting workload into primary care without proper planning will only exacerbate already unsustainable demands on primary care services and hamper efforts to diagnose cancers earlier.
Patient groups also welcomed the announcement. When worrying symptoms develop, patients want to be assessed and reassured or diagnosed and treated in a timely manner.3 A Healthwatch report of patient experiences at community diagnostic centres in Brighton and Hove found these centres were generally well received, particularly if all necessary testing could be done concurrently and close to people’s homes. GPs were identified as having a key role at the start and end of the process to explain why imaging was necessary and discuss the findings. Patients reported that clear communication sensitive to their needs was vital. They also wanted clarity on how community diagnostic centres fitted into their local NHS services.10
No quick fix
The NHS in England will need to overcome several serious challenges to successfully widen direct access to diagnostic imaging from primary care. New services must be used appropriately to avoid worsening already long backlogs or increasing diagnostic delays through suboptimal use of imaging.11 Incidental and indeterminant findings, such as small pulmonary nodules on computed tomography (CT) scans, could lead to overdiagnosis and overtreatment in some patients.12
Diagnostic delay is a chronic problem that has been exacerbated by the covid-19 pandemic. Over 1.5 million patients were waiting for a diagnostic test at the end of October 2022; the target of no more than six weeks between a GP referral and the requested diagnostic imaging has not been met since early 2017.13
Lengthy waiting times are also the result of underinvestment in diagnostic capacity and worsening workforce shortages. Among 38 countries in the Organisation for Economic Cooperation and Development, England ranks 34th and 31st respectively1415 in the number of CT and MRI scanners per million population. Additionally, the ever growing NHS maintenance backlog16 means some older imaging equipment is already unreliable and does not have the resolution required for acceptable diagnostic quality. The NHS is short of both radiographers to do the tests and radiologists to report on them. The Diagnostic Radiography Workforce UK Census in 2020 showed an average vacancy rate of 10.5%, with some variation between the four nations of the UK.17 The Royal College of Radiologists estimates the current workforce shortfall for radiologists stands at 1699 and could rise to 3166 by 2026 without additional investment.18 Efficiency gains—including relatively simple measures such as reorganising the working hours of imaging services or redeploying scanners to complete initial diagnostics in community settings—would not compensate for these substantial gaps in staffing.
The NHS England announcement has been welcomed in principle by patients and clinicians. More direct access imaging has the potential to reduce waiting times and may increase the proportion of cancers diagnosed at earlier stages. However, the policy is doomed to fail if substantial investment in new diagnostic infrastructure and workforce capacity does not follow.
Footnotes
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare no other interests. Further details of The BMJ policy on financial interests are here: https://www.bmj.com/sites/default/files/attachments/resources/2016/03/16-current-bmj-education-coi-form.pdf
Provenance and peer review: Not commissioned; externally peer reviewed.