New audits provide GPs with tools to improve cancer diagnosis

In Greater Midlands Cancer Network practices covering just under half of the population carried out the audit, which assemble the facts around recently diagnosed cancers, picked two problematic cases for the SEA, and held a practice meeting to discuss the findings.

GP adviser Bruce Eden says most GPs found it a useful exercise, providing time to reflect and insight into what they and their colleagues were doing.

‘Some practices found that locums were not following procedures, some practices hadn’t got proper safety netting, to ensure that patients with abnormal test results came back to get the results, and some practices didn’t use the NICE referral criteria or pro-formas for two week wait referrals.’

Bruce believes that as well as helping GPs to see where they can improve, the audit points to ways that the network can help, such as writing guidelines about safety netting.

His comprehensive report on the audits has been accepted by the Greater Midlands Cancer Network board and the many recommendations are now being taken forward. For instance, the network website will be developed to provide links to information for the public about symptoms as well as publishing data at PCT level on cancer referrals with the option of individual practices and GPs requesting information about their own performance.

Anglia Cancer Network GP lead David Plume, who has checked every one of the 100 or so audits carrried out in his network so far, says some GPs have already changed their practice in response to the audit, even though the results have not yet been fully analysed. ‘One GP said she had realised her surgery were managing too many things in house and were not referring people quickly enough.’ Another practice has decided to run the audit every year because it was so helpful.

South East London Cancer Network primary care lead Cathy Burton adapted an audit tool used in Scotland, an experience that contributed to the development of the RCGP/NCAT tool. She believes the audit is valuable in raising awareness among GPs, particularly of the referral guidelines, as there are 13 different forms for the different types of cancer.

After the initial audit in her own PCT Lambeth, Cathy worked with three other PCTs on the audit and the more reflective significant event audit (SEA). The SEAs of each practice’s last two cancer cases have thrown up a number of practical issues, such as ensuring that GPs have an up to date phone number for patients in case they need to contact them urgently when test results come back and how communication works when patients opt to be referred privately. But the SEA also raised more general questions, such as how best to work with patients who may be unwilling to attend investigations or be referred to hospital. ‘The SEA was an important learning tool, and promotes effective practice in primary care,’ she says.

By far the most detailed picture has emerged from a significant event audit of the last lung and teenage and young adult cancers to be diagnosed in 90 practices in Durham, Darlington and South of Tyne and Wear. Greg Rubin, who helped to develop the SEA for the National Cancer Action Team, has taken the process to a new stage by analysing the results of all SEAs for the two cancers together.

For lung cancer, some of the issues that jumped out were treatment of abnormal results, co-ordination between different GPs and other staff within a practice, safety netting and active systems to ensure that patients come back in. As a direct result of the audit, rapid process improvement workshops are being run to try to speed up the commissioning and reporting of chest X-rays.

The SEA of the lung cancer cases showed what a tricky disease it can be to diagnose. ‘Lung cancer doesn’t always present typically; vigilance over symptoms in smokers and people with existing chest problems is needed but the disease can also appear in non-smokers while chest X-rays can give false negatives.’

Greg says it has proved more difficult to draw conclusions from the teenage and young adult cancers because there were fewer cases, 35 instead of 132, and more different cancers involved. But the SEAs did point to one particular scenario that GPs should watch out for, namely the ‘sports injury’ that doesn’t clear up. The SEA also prompted questions about how best to communicate with young people, and particularly young men, who may be loath to visit the doctor or to talk about their symptoms.

Richard Cullen from Rotherham PCT believes the national audit is particularly valuable as PCTs prepare to make cuts in their budgets. Savings made by improving the process of diagnosis could then be invested in awareness initiatives. ‘I think follow-up is the big issue for cancer leads to address to achieve savings.’

The audit and the SEA can also provide insight for policy makers. David Plume in Anglia was surprised to find that GPs were not clamouring for direct access to diagnostics. Only a small minority, between 4 and 8% of those completing the audit said that they would have been able to diagnose faster if they had had access to CT scans, endoscopy, MRI or ultrasound.

Avon, Somerset and Wiltshire Cancer Network associate medical director Alison Wint is looking forward to seeing the results of her main audit, having piloted the national template with a small sample. ‘It will be interesting with the bigger numbers to look at particular cancers and see if there is any correlation with time to presentation and time to referral and the stage of the disease. You have to have an open mind. What you find may not be what you expect.’

Anglia Cancer Network Primary Care Lead David Plume dplume@nhs.net
Avon Somerset and Wiltshire Cancer Services associate medical director Alison Wint alison.wint@nhs.net
Greater Midlands Cancer Network GP Adviser Bruce Eden Bruce.Eden@wolvespct.nhs.uk
Durham University professor of general practice and primary care Greg Rubin g.p.rubin@durham.ac.uk
North Trent Cancer Network primary care representative Richard Cullen Richard.Cullen@rotherham.nhs.uk
South East London Cancer Network primary care lead Catherine Burton calburton@gmail.com

• Primary Care Cancer Audit: Greater Midlands Cancer Network Report by Dr Bruce Eden and Andrew Davies
• Cancer in Primary Care: An analysis of significant event audits (SEA) for diagnosis of lung cancer and cancers in teenagers and young adults

Case study written by Ros Bayley on behalf of the National Cancer Action team