Understanding Referrals
An overview for Primary Health Care Teams
1. The NICE Referral Guidelines
What are the guidelines?
Referral guidelines for primary care for suspected cancer were first published by
NICE in 2000. Improvements have been made in the timely diagnosis and treatment
of cancer patients, however some patients with suspected cancer are still not being
referred urgently which leads to a delay in treatment.
The national guidelines have now been updated to better help practitioners
distinguish between symptoms associated with common illnesses, and those that
might indicate cancer.
The revised guidelines cover the referral processes for the following tumour types:
 Lung
 Upper and lower GI
 Breast
 Gynae
 Urological
 Haematological
 Skin
 Head and Neck incl. thyroid
 Brain and CNS
 Bone cancer and sarcoma
The guideline also considers cancers seen in children and young people, and
support and information needs for patients. The full suite of information can be
viewed on the NICE website at: http://www.nice.org.uk/page.aspx?o=261649.
Copies of the Quick Reference Guide for clinicians and information for the public are
included on this CD-Rom.
How do the changes affect Primary Health Care Teams?
The guidelines contain changes to the criteria for urgent suspected cancer referrals,
with additional information to support other types of referrals and the management of
patients within primary care.
The urgent referral fax proformas used by GPs in South East London have been
modified to reflect these changes, and are available from the Cancer Network
website www.selcn.nhs.uk. Click here for more information about urgent referrals.
Primary Health Care Teams are also required to provide information and support to
patients during the referral process. This includes information about the possible
diagnosis and where they are being referred to, and providing culturally appropriate
care. Click here for more information about patient information and support.
2. In the consultation
The NICE guidance states that GPs should be familiar with and able to readily
identify the typical presenting features of cancers, and take part in continuing
education, peer review and other activities to improve and maintain these skills.
GPs should review the patient history, examination and initial diagnosis and refer if
necessary when common symptoms do not resolve as expected, if confronted by
unusual symptom patterns or if patients thought not to have cancer fail to recover as
expected.
Cancer is uncommon in children, and its detection can present particular difficulties.
GPs should listen carefully to the concerns of parents, and discuss the diagnosis with
a colleague or specialist when a child fails to recover as expected, or there is
uncertainty about how to interpret the symptoms and signs.
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Understanding Referrals
An overview for Primary Health Care Teams
The information and support needs of the patient should be assessed during the
consultation – click here for more information.
3. How to refer patients
Immediate referrals
Admission to an acute Trust or a referral occurring within a few hours, or even more
quickly if necessary, should be made when a patient presents with severe or life
threatening symptoms. The guidelines indicate which clinical symptoms are
appropriate for an immediate referral, and these are included for information on the
urgent suspected cancer referral proformas.
Urgent referrals (Two Week Wait)
A patient who is referred urgently is seen within the national target – currently two
weeks. This route should be used for patients in whom the GP suspects cancer.
The revised NICE guidelines set out the clinical symptoms and findings that are
appropriate for urgent referral.
To make an urgent referral the GP should complete the SELCN urgent referral
proforma and fax it to the relevant hospital within one working day of seeing the
patient. Revised proformas are available on this CD-ROM.
The proforma is a two-page document – the front side is used to record the patient
details and clinical information, the reverse contains the referral criteria and other
supporting information. Only the front sheet needs to be faxed. Additional relevant
information can be included on separate pages if necessary. Please include a print
out of the patient’s computer record summary of relevant past medical and social
history, medication and allergies when available.
In most places a central appointments team receives the faxes, and phones the
patient the next day to confirm an appointment time within the next two weeks with
them. If patients cannot be contacted by phone the appointment details are sent in
the post. Patients will also be sent some basic information about who will see them
and whether they will have tests.
Adults should normally be told that they are being referred to a cancer service, but if
appropriate provide reassurance that most people who are referred will not turn out
to have a diagnosis of cancer. At the very least your patient should be aware that
they will be offered an appointment within the next two weeks. A simple leaflet to
support this conversation is available on this CD-ROM for GPs to use.
Non-urgent
All other referrals are classed as non-urgent. The urgent suspected cancer referral
proformas also contain information on which clinical symptoms are appropriate for a
non-urgent referral.
Non-urgent referrals should be made by letter or using the new Choose & Book
system within one working day of seeing the patient. Be sure to include all
appropriate information in referral correspondence, as the referral will be vetted by
clinical teams at the hospitals and prioritised according to urgency of the signs and
symptoms.
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Understanding Referrals
An overview for Primary Health Care Teams
4. Patient information and support
The revised NICE guidelines make a number of recommendations about the support
and information that should be offered to a patient at the time of referral.
Assessing patient needs
Primary healthcare professionals should provide culturally appropriate care,
recognising the potential for different cultural meanings associated with the possibility
of cancer, the relative importance of family decision-making and possible
unfamiliarity with the concept of support outside the family.
Ensure patients are able to consult a primary healthcare professional of the same
sex, if preferred.
Discuss with patients (and carers as appropriate) their preferences for being involved
in decision-making about referral options and further investigations (including risks
and benefits).
Take into account personal circumstances, such as age, family or work
responsibilities, isolation, or other health or social issues.
Referring the patient
Normally tell adults that they are being referred to a cancer service, but if appropriate
provide reassurance that most people who are referred will not turn out to have a
diagnosis of cancer.
In children and young people, discuss the referral decision and any information
needs with the parents or carers (and the patient, if appropriate).
Follow current advice on communicating with patients and/or their carers and
breaking bad news.
The primary healthcare professional will be aware that some patients find being
referred for suspected cancer particularly difficult because of their personal
circumstances, such as age, family or work responsibilities, isolation, or other health
or social issues.
Inform the specialist of any additional support needs, with the patient’s agreement.
In situations where diagnosis or referral has been delayed, or there is significant
compromise of the doctor/patient relationship, take care to assess the information
and support needs of the patient, parents and/or carers, and make sure these needs
are met. Give the patient an opportunity to consult another primary healthcare
professional if they want to.
“I felt like I was
causing trouble…”
(Bexley patient)
“The GP didn’t try
to find out why I
was in pain…”
(Southwark patient)
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Understanding Referrals
An overview for Primary Health Care Teams
After the consultation
Assess the patient’s need for continuing support while waiting for their referral
appointment. Invite the patient to contact you again.
“My GP has offered
me support while
being treated…”
(Southwark patient)
Consider the information and support needs of patients and
the people who care for them.
Have information available in a variety of formats on both local
and national sources of support.
Be aware that men are likely to have similar support needs to women, but may be
more reticent about using support services.
Useful resources for GPs
 Information on tumour types
More information about tumour types and the tests a patient might have is available
from Cancer BACUP – call 0808 800 1234 or visit the website:
www.cancerbacup.org.uk.
 Cancer Service Directories
Several acute Trusts have produced a Directory of Cancer Services for primary
health care teams to use. They are available on this CD ROM, along with other local
information directories.
 Breaking Bad News
The Cancer Network has summarised guidelines for breaking bad news to a patient
in a leaflet. The summary and the full guideline are available on this CD-ROM.
Cancer patients and carers across South East London, in partnership with Macmillan
and the Cancer Network, have made a video documenting how significant news was
broken to them, and how their experience could have been improved. Copies will be
available in Primary Care and Acute Trusts to use with clinical and management
teams. For more information contact Bonnie Yandall, User Partnership Facilitator for
the Cancer Network, on 020 7593 0160 / bonnie.yandall@selondon.nhs.uk.
 Patient experience of referrals
The user partnership group in Bromley (known as Voices In Bromley) identified the
initial part of many cancer patients journey - where patients become aware of
symptoms, go to their GP and are referred to hospital - as an area they would like to
improve. They asked patients from other parts of South East London about their
experiences of GP consultations and referrals, collated the results and are now
identifying ways to improve the referral process. The full report is available on this
CD ROM. For more information please contact Pip Wittenoom, Primary Care Service
Improvement Facilitator for the Cancer Network, on 020 7593 0160 /
pip.wittenoom@selondon.nhs.uk.
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Understanding Referrals
An overview for Primary Health Care Teams
5. National waiting times targets
First seen for
suspected cancers
GP referral for
suspected cancer
Diagnostic phase (CT,
MRI, endoscopy,
biopsy, etc) and MDT
First Treatment
Decision to Treat made
14 days
31 days for all cancers
62 days for all cancers
from urgent GP referral.
There are three Cancer Waiting Times targets that Acute and Primary Care Trusts
are actively being monitored against:
 All urgent cancer referrals from GPs seen within two weeks (14 days)
 31 days from cancer diagnosis to treatment for all patients
 62 days from urgent cancer referral by a GP to first treatment.
Across South East London we are routinely achieving the two-week target for urgent
referrals and in most cases the 31-day target from diagnosis to treatment. Over 90%
of urgent referrals are treated within 62 days, and a great deal of work is going into
improving these results for all patients.
6. Feedback & Performance Management
Each Acute Trust cancer multidisciplinary team is required to provide information to
referring GPs and other PCTs on the ‘appropriateness’ and timeliness of urgent
suspected cancer GP referrals. In this context the term appropriate means whether
the referral has been made in accordance with the agreed referral criteria listed on
the reverse side of the referral proforma.
The Acute Trusts should also monitor and feed back to PCTs and individual GPs the
 number of patients referred as urgent,
 proportion of urgent referrals who are subsequently found to have cancer, and
 numbers of routine referrals who are found to have cancer.
Some Trusts in South East London already have these audit and feedback
processes in place, while others are developing them at present.
Nationally, studies show that 15 -20% of patients referred as urgent suspected
cancer referrals are diagnosed with cancer. An ongoing area of concern is that many
patients who do have cancer are not being referred on the 2-week route. As a local
example, approximately 5% of patients referred with suspected colorectal cancer are
subsequently diagnosed with cancer, and up to 74% of patients who do have
colorectal cancer are not referred urgently.
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