Professor Willie Hamilton specialises in primary care diagnostics at the University of Exeter.
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The original cancer problem was that we weren’t testing smartly enough. When I became a GP over 30 years ago, we didn’t know well enough who of those walking through the doors to our GP surgeries could be harbouring cancer, so the big push was to be better at identifying the different levels of cancer risk associated with different symptoms and test results to inform who needed testing and who didn’t.
It feels like we’ve got there now – the guidance issued by the National Institute of Health and Care Excellence (NICE) in 2015 was the high citadel of testing smarter: the previous guidance in 2005 simply not having enough evidence behind its recommendations. The other paradigm-shifting in 2015 was the decision to give an explicit risk of cancer that warranted urgent testing – and in being ambitious in setting it as low as 3%. Even more liberal was encouraging GP testing at lower risks than 3%.
But if we stick to the 3% rule outlined in the NICE guidance – that you urgently refer or do tests only if someone’s symptoms equate to a 3% risk of cancer or greater, there will be some people that will never get testing and will end up presenting as an emergency. We will only be able to capture those people if we’re prepared to test more. We can only test more if we make it patient friendly and economically friendly. Both of those factors point towards stationing it closer to the patient – in general practice or on the high street.
This won’t work for all presentations I hasten to add – GPs will still need to refer patients to hospital for some tests. We don’t have the technology in primary care to do the tests for a woman with a breast lump, for example, so we need to get the experts involved. But there are many other cancers where you can move towards more testing outside of hospitals. Things like chest X-rays, blood counts, platelet counts, but also more sophisticated tests like CA125 or ultrasound to pick up potential ovarian cancer and in the future potentially blood tests that pick up cell-free DNA.
GPs are evolving
It’s a win-win. From a patient perspective – the closer to home you can do tests, the easier, more familiar, and hopefully nicer, it will be. It’s also likely to be cheaper, and you may get your results back quicker – because at least you’ve got your GP’s phone number.
The question is – are we blurring the line by moving more testing to primary care or community settings such as community diagnostic hubs recently recommended in Professor Sir Mike Richards’ review of diagnostic services? Some GPs may say yes, some specialists may say yes. It’s never going to be a unanimous decision – there are 40,000 GPs in the UK with I would imagine around 40,000 different opinions on the best way to deliver care.
But I would argue that the line has been blurring for years. Stretching the limits of primary care is a part of its history. The truth is primary care evolves, GP practices evolve. In time, practices that were inconceivable become the norm.
Take Faecal Immunochemical Testing (FIT). It was used only as part of bowel screening, but a few years ago NICE brought it in to test people who had low-risk symptoms below the threshold for referral for a colonoscopy for suspected bowel cancer, but where something might be going on that needed investigating. It wasn’t a popular decision at first – there was tremendous fear within the surgical community that using FIT in people with such symptoms would lead to an influx of patients without disease, which would overwhelm endoscopy services.
But the doomsayers missed two points that have turned out to be true. The first was, if someone had a positive FIT, they were no longer low risk, they became quite high risk – 11% of people who tested positive went on to be diagnosed with bowel cancer. The other point was they were lowering their threshold for testing anyway: ‘low-risk’ patients were being offered colonoscopies. Fair enough, as there was no other test. So bringing in FIT as a way of sifting in primary care actually reduced pressure on endoscopy services.
The icing on the cake
There are so many reasons why increasing testing is smart. Firstly, patients want it – if cancer is even a remote possibility people want to know. The other thing is, general practice is not simply painting by numbers. I don’t particularly like the phrase ‘gut feeling’, though intuition is a bit better. It’s experience: let’s call it the icing on the cake – the experience that helps a GP see something unusual, the classical ‘needle in the haystack’. Giving GPs more flexibility with how they can test will mean they can more easily navigate patients through the complex health system we have.
But can the NHS cope? We know the NHS is stretched – and cancer is an area where specialists are living with limitations to the number of personnel and equipment they have available. But as we’ve seen a number of times, moving testing into a community setting – be that in GP practices or future community diagnostic hubs – can help alleviate pressure by helping to identify people who do need further tests or treatment.
And when it comes to GPs, I think we can handle it. I’m not saying we need to test everyone who comes through the door – we are experts in managing risk. I’m talking about one or two patients a week that warrant a more liberal approach to testing, you do a test and then if it’s positive, you refer them on. That’s not rocket science.
Of course, with more testing we may find more things that aren’t cancer, which could contribute to increased anxiety and more demand on the health service. But if we are to shift outcomes for cancer the way UK Government says it wants to, we have to be proactive and go looking for cancer, not wait for it to come to us. By that time, it could be too late.
And now may be the perfect time. Before COVID-19, general practice was struggling to provide the highest quality care that we want to offer. My colleagues were sinking in a pile of paperwork, but also in their own successes – we’re keeping people in the UK alive for longer, and that means more people to see and more conditions to treat and manage.
It’s a strange thing to say, but COVID-19 might have saved general practice. It forced us to redesign and take stock. The wholesale switch to remote consulting has shown us that there are ways of dealing with patients’ problems that are acceptable. There’s a lot of debate around that and how we’ll work in the future, but I think it’s safe to say that we’ll never 100% switch back.
As always, we’re evolving – and a shift towards increased testing to further drive improvements in outcomes for patients should be a part of that.
About the author
Professor Willie Hamilton specialises in primary care diagnostics at the University of Exeter, with a particular expertise in cancer. He was clinical lead on the main NICE guidance ‘Referral for Suspected Cancer’ NG12, published in 2015, which have contributed to meeting the target of reducing the number of avoidable cancer deaths in the UK by 10,000. Hamilton and his team have also produced Risk Assessment Tools for all major adult cancers, providing the GP and patient with an accurate estimate of the risk of cancer when a patient reports symptoms to their GP.
Hamilton is a third generation doctor from Belfast.