Intended for healthcare professionals

Opinion Taking Stock

Rammya Mathew: Are we a cancer service or a health service?

BMJ 2023; 381 doi: (Published 20 June 2023) Cite this as: BMJ 2023;381:p1382
  1. Rammya Mathew, GP
  1. London
  1. rammya.mathew{at}
    Follow Rammya on Twitter: @RammyaMathew

For years, cancer survival rates in the UK have lagged behind those of other countries with comparable wealth and income.12 In response, in 2015 NICE published new guidance on the referral of suspected cancer in primary care, explicitly specifying that any symptom constellation that conferred a 3% or greater risk of representing a cancer diagnosis should automatically be referred through an urgent “two week wait” referral pathway.3

Researching the rationale for the 3% threshold led me to discover that this wasn’t based on robust economic analysis—just that the guideline development group believed that such a change “would not overwhelm clinical services, nor would it greatly increase the possible harms to patients from over-investigation.”3 But did they foresee that referrals for suspected cancer would rise exponentially,4 or that in coming years we’d have more than seven million people waiting for elective care on an NHS waiting list?5

It’s true that some cancer outcomes have improved since the change in guidance, with fewer diagnoses made through emergency presentations and more diagnoses at an earlier stage of disease.5 But surely cancer survival is what matters to patients, and we can’t say with any certainty how much this has improved, as we can’t determine the inevitable effect of lead time bias that goes hand in hand with earlier diagnosis. And how do we judge whether this improvement is proportionate to the additional resources required to support the increase in activity generated by these guidelines?

Cancer is an emotive topic: most of us have been affected by it, directly or indirectly, and there will always be a drive to do better. Colleagues working in the specialty tell me that patients want the referral threshold to be even lower—and in recent weeks we’ve also seen a request for more resources to enable cancer services to meet their targets for diagnosis and treatment.6

Looking at the current state of healthcare in the UK, however, I’m worried that the NHS is being reduced to a service that does relatively well for patients with cancer and possible trauma, while those with other complex and life limiting conditions struggle to get the same levels of care. Heart failure, for example, has a worse mortality rate than many common cancers,7 yet services don’t have nearly enough capacity to deliver the care and coordination these patients require. And when it comes to mental health services, my heart breaks for patients who get threadbare support even during periods of extreme crisis. How might we fare if we had robust data to support international comparisons of outcomes in key areas other than cancer?

I’m not advocating a race to the bottom, but rather a levelling of the playing field. There has to be parity: between physical and mental health and between cancer and other diseases that carry significant morbidity and mortality. The question is, where does the 3% referral threshold sit in this equation?


  • Competing interests: None.

  • Provenance and peer review: Commissioned; not externally peer reviewed.