DIRECT ACCESS TO DIAGNOSTICS
Final Report
North of England Cancer Network
Kathryn Jones
Linda Wintersgill
January 2013
FINAL REPORT DISTRIBUTION:
Cancer In the Community Group
Cancer Unit Managers
CCG’s
GP Cancer Leads
NECN Exec Team/ NECN Board
Network Site Specific Groups (Gynae, Lung, Brain & CNS)
Radiology Cross Cutting Group
SHA – James Martin
CONTENT
INTRODUCTION..............................................................................................................
3
AIM ..................................................................................................................................
3
METHOD .........................................................................................................................
4
FINDINGS ………………………………………………………………………………………. 4
NON-OBSTETRIC ULTRASOUND .................................................................................. 5
SUMMARY (Non-obstetric Ultrasound).....................................`............................ 11
CHEST X-RAY ................................................................................................................. 12
SUMMARY (Chest X-Ray).................................................................................... 18
MRI BRAIN ....................................................................................................................... 19
SUMMARY (MRI Brain) ........................................................................................ 27
CONCLUSION .................................................................................................................. 29
RECOMMENDATIONS...................................................................................................... 30
NEXT STEPS ……………………………………………………………………………….….
30
REFERENCE .................................................................................................................... 31
ACKNOWLEDGEMENTS.................................................................................................. 31
APPENDIX ........................................................................................................................ 32
INTRODUCTION
Patients continue to be diagnosed with cancer at a late stage, therefore reducing their
chances of survival (IOSC 2011). Improving Outcomes: A Strategy for Cancer sets out its
commitment to earlier diagnosis (DH 2011).
Invariably GP’s are the first port of call to detect signs and symptoms of cancer, and where
there is a suspicion of cancer the GP has the facility to refer patients into rapid access
clinics to see a specialist via the 2 week urgent referral pathway (NICE 2005).
However, there are times when a referral is outside of this pathway, but still requires urgent
diagnostic investigation. For this purpose DH committed funding to support direct access for
GP’s to access diagnostic testing to help them diagnose or exclude cancer earlier. DH
recommended that Commissioners and local providers consider four priority areas.
Non-obstetric ultrasound - Evidence has shown that patients presenting to GP’s with
symptoms of ovarian cancer and investigated earlier would equate to earlier diagnosis (DH
2011)
Chest X-ray - Late stage diagnosis for lung cancer continues - The National Lung Cancer
Audit (2010) showed that 70% of cases were stages IIIB or IV at the time of diagnosis (DH
2011)
MRI Brain - Over 50% of patients with a brain tumour present to A&E (NCIN 2010). There
is variation across the country with an urgent referral processes along with disparity to GP
direct access to MRI brain (DH 2011)
Flexible-sigmoidoscopy – 25% of patients diagnosed with colorectal cancer present
through an emergency presentation (NCIN 2010). The availability of direct access to
flexible-sigmoidoscopy for GPs is currently variable.
DH developed Best Practice Referral Pathways for General Practitioners (DH 2011)
covering the process for direct referral by GPs to these specific tests for the assessment of
particular symptoms where cancer may be suspected but the urgent GP referral (2WW)
process is not applicable.
AIM
Mapping 1 – Radiology/GP
The rationale to this mapping is to ascertain what Radiology direct access diagnostic
services are provided by secondary care for Non-obstetric ultrasound (NOUS), Chest X-ray
(CXR) and MRI brain to GP’s across the North of England Cancer Network and understand
GP perception of this service provision.
Mapping 2 – Endoscopy/GP
A further mapping exercise is planned to understand flexible sigmoidoscopy (flexi-sig)
access with the relevant diagnostic departments in secondary care as well as establishing
GP’s perception of this service.
Both mapping exercises will determine where there are any gaps in service and provide
recommendations on the outcomes.
METHOD
Distribution of questionnaires to Hospital Radiology Departments and all GP Practices
across NECN.
Analysis of data to assess actual and perceived service provision across the network.
FINDINGS
10 Hospital Radiology departments responded to the questionnaire.
17.5% of GP’s/Practice’s within the Network responded to the questionnaire.
NECN would like to acknowledge the contribution made by those within primary and
secondary care.
From the data collected it is not clear who in the GP Practices was responsible for
completion of the survey, i.e. GP or another member of Practice staff. Different people in the
practice may have different perceptions of the timescales involved for these services and
therefore contribute to some of the variation reflected in responses.
This report will give a summary of findings at the end of each diagnostic section.
NON-OBSTETRIC ULTRASOUND
There were 79 GP Practice responses to the questionnaire.
77 Practices confirmed they have direct access to this test.
2 Practices said they did not have direct access (1 Practice in Cumbria; 1 in North
Tyneside).
All Hospitals confirmed that direct access is available.
GP Q2. Which hospital do you refer to?
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3 GP Practices did not confirm where they accessed services. Generally Practices refer to
their ‘nearest’ Hospital.
Appendix 1 gives an abbreviation key to the above referral sites.
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GP Q3. How do you refer for this type of scan?
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Most GP Practices (53.2%) indicated that paper submission of requests is the most
common, followed by electronic submission. Some Practices use a variety of request media.
Radiology (Non-obstetric ultrasound):
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All Hospitals, with the exception of Sunderland, accept paper based requests and a number
accept Choose & Book requests. A number of Hospitals accept more than one referral
method and this was reflected in GP Practice responses – although there is no indication of
why one media might be chosen over another in either case.
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GP Q4. Do you have referral protocols which you must adhere to?
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70.1% of GP Practices indicated that there were no referral protocols to adhere to for this
type of test. Almost one quarter of responding Practices indicated that referral protocols do
exist – there is no indication why Practices in the same area have differing views.
GP Q7. Current waiting time for this type of scan in Days (routine and urgent)?
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GP Practice responses (above) show that the waiting times for Urgent requests is generally
shorter than Routine requests.
Almost half of GP Practices (49.4%) indicated that urgent waiting times were in excess of 28
days. However, data for Hospitals (below) show much shorter wait times than reflected in
Practice responses; for urgent referrals all Hospitals indicate waiting times of 2 weeks or
less.
Almost three quarters of responding Practices indicate wait times in excess of 3 weeks for
routine referrals; 60% over 28 days. For Hospitals routine wait times range from 6 days in
North Cumbria to 42 days in CDDFT, this does not reflect Practice experience.
4
Radiology (Non-obstetric ultrasound): Current waiting times
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GP Q8. In days, how long do you wait to access a “signed/verified” report?
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Whilst a number of GP Practices (31.2%) would access a “signed/verified” report within 7
days, most (42%) would wait in excess of 28 days (though it is not clear from responses if
this is from date of referral or date of scan). The table below shows Hospital reporting times
– a number of which is same day turnaround which is not reflected in Practice responses.
Radiology (Non-obstetric ultrasound): What is the current “reporting time” for this
type of scan?
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All Hospitals, with the exception of North Tyneside and Royal Victoria Infirmary provide
electronic reports, though some still rely on post or fax to forward results. For Hospitals with
multiple methods, there is no information on criteria applied to method chosen.
Radiology (Non-obstetric ultrasound): Incidental Findings
Only North Tees & Hartlepool indicated that a 2 week wait referral is not suggested within
the report to the GP if an ‘incidental finding’ is found on this type of scan. It was commented
that reporters identifying an ‘incidental finding’ would arrange for a fax to be sent to the
referring GP Practice to escalate, however this comment does not indicate which radiology
examination this refers to.
SUMMARY (Non-obstetric ultrasound)
All Hospitals provide direct access for non-obstetric ultrasound.
When referring patients for this examination it was found that paper submission was the
most common.
There was only one Hospital which accepted a single referral system of electronic referrals;
however there were a number which accepted paper and electronic referrals.
70% of GP’s indicated there were no referral protocols to adhere to when referring their
patients.
There is an anomaly between Hospital waiting times and the waiting times perceived by GP
Practices. Some GP Practices stated a wait in excess of 28 days.
There does appear to be a delay in accessing “signed/verified” reports, 42% waiting in
excess of 28 days.
80% of Hospitals provide electronic reports, however, some do still reply on post or fax.
CHEST X-RAY
There were 79 GP Practice responses to the questionnaire.
78 Practices confirmed they have direct access to chest x-ray.
1 Practice did not provide a response.
All Hospitals confirmed that they provide direct access for this test.
GP Q2. Which hospital do you refer to?
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3 Practices did not confirm where they accessed services. Generally Practices refer to their
‘nearest’ Hospital.
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GP Q3. How do you refer for this type of scan?
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Most GP Practices (51.3%) indicated that paper submission of requests is the most
common, followed by electronic submission (37.2%). Some Practices use a variety of
request media.
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Most Hospitals, with the exception of Queen Elizabeth, accept paper based requests; only
James Cook accepts Choose & Book requests. A number of Hospitals accept more than
one referral method and this was reflected in Practice responses – although there is no
indication of why one media might be chosen over another in either case.
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GP Q4. Do you have referral protocols which you must adhere to?
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Most Practices (75%) indicated that there were no referral protocols to adhere to for this test
– though it is interesting that difference of understanding exist within areas.
GP Q7. Current waiting time for this type of scan in days (routine and urgent)?
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Practice responses show (above) that the waiting times for urgent requests is generally
shorter than for routine requests.
For chest x-ray over 52% of GP Practices indicate urgent waiting times of 3 days or less; but
almost one third indicate waiting times in excess of 28 days. In most cases Hospitals
indicate no wait time for chest x-ray and the longest wait indicated by Hospitals is 2 days –
whilst this is broadly in line with those Practices which indicate shorter waits; it does not
account for much longer waits reported by others.
For routine referrals, 50% of GP Practice responses indicated wait times of 7 days or less
(46% 3 days or less). However over 37% of responding Practices indicated patients would
wait longer than 3 weeks for a routine appointment. Conversely Hospital responses (below)
range from 0 days to 6 days for a routine chest x-ray.
Radiology (Chest x-ray):
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GP Q8. In days, how long do you wait to access a “signed/verified” report?
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Less than half (44.9%) of responding Practices would access a “signed/verified” report within
7 days, but 30% would still wait in excess of 28 days (though it is not clear from responses if
this is from date of referral or date of scan).
The table below shows Hospital reporting times – all of which are considerably less than the
interval reported by many of the responding Practices.
Radiology (Chest x-ray): What is the current “reporting time” for this type of scan?
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Radiology (Chest x-ray): How does the GP receive the ‘signed/verified’ report?
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All departments with the exception of RVI provide electronic reports; and most also use post
and/or fax to forward results. For Hospitals with multiple methods, there is no information on
criteria applied to the method chosen for dissemination.
Radiology (Chest x-ray): Incidental Findings
All Hospitals providing direct access to chest x-ray indicated that a 2 week wait referral is
suggested within the report to the GP if an ‘incidental finding’ is found on an image.
.
SUMMARY (Chest x-ray)
All Hospitals provide direct access for chest x-ray.
Most Hospitals accept paper based requests for this type of examination.
Practices indicated this was the most common form of referral.
Most GP
5 Hospitals do not accept electronic referrals.
75% of GP Practices indicated there were no referral protocols to adhere to.
In most cases hospital waiting times are 2 days or less for urgent referrals, although North
Tyneside reported a wait of up to 7 days.
One third of GP Practices indicated a waiting time in excess of 28 days. Over 52% indicated
a wait time of 3 days or less.
Most Hospitals provide electronic reports, however, some still rely on post or fax.
Less than half of responding Practices would access a “signed/verified” report within 7 days,
however 30% stated they would wait in excess of 28 day. There appears to be a disparity
between the Hospital and GP responses for this service.
4
MRI BRAIN
There were 79 GP Practice responses to the questionnaire.
24 (30%) Practices confirmed they have direct access to this test.
50 Practices reported they do not have direct access to this test; 3 did not know and 2
provided no response to this question.
From Hospital responses (shown below) it can be seen that most Hospitals provide direct
access to GPs for this test. However, Sunderland indicates no direct access service, yet 3
Practices responded that they have direct access for this test at Sunderland; further
investigation into this shows that the 3 Practices in Sunderland have an existing fund holding
contract which reflects inequity of service. Similarly North Cumbria indicates no direct
access for GPs yet one Practice reported direct access at West Cumberland Hospital for this
test.
Radiology (MRI Brain):
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GP Q2. Which hospital do you refer to?
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1 Practice did not confirm where they accessed services. Generally Practices refer to their
‘nearest’ Hospital.
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GP Q3. How do you refer for this type of scan?
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Most GP Practices (62.5%) indicated that paper submission of requests is the most
common, followed by electronic submission. A small number of Practices use Choose &
Book systems.
Radiology (MRI Brain): Method of request
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All Hospitals who provide this service accept paper based requests; with Choose & Book
and Electronic requests available in some cases. Some Hospitals accept more than one
referral method – although there is no indication of why one media might be chosen over
another in either case.
*
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GP Q4. Do you have referral protocols which you must adhere to?
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GP Practices are equally split about whether specific referral protocols are used or not – and
responses vary within the same geographical area.
GP Q7. Current waiting time for this type of scan in Days (routine and urgent)?
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GP Practice responses (above) show most Practices are unaware of current waiting times
for this test – whether urgent or routine.
For urgent waiting times there is a broad spectrum of wait times with differing results across
a single patch. Hospital responses (below) show a maximum waiting time for urgent
referrals of 14 days – but this is not generally reflected in Practice responses.
For routine referrals, almost 40% of GP Practice responses indicate wait times in excess of
28 days. This is broadly in line with Hospital responses which range from 25 days to 42
days for a routine referral.
Radiology (MRI Brain): Current Waiting Times
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GP Q8. In days, how long do you wait to access a “signed/verified” report?
One third of GP Practices (8/24) either did not know or did not respond to the question of
how long they would wait before accessing a “signed/verified” report. There were 7
Practices which indicated more than 28 days.
The table below shows Hospital reporting times, all of which are considerably less than the
interval reported by many of the responding Practices.
Radiology (MRI Brain): What is the current “reporting time” for this type of scan?
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Radiology (MRI Brain): How does the GP receive the ‘signed/verified’ report?
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Most Hospitals (5/9) provide electronic reports, though some still rely on post or fax to
forward results. For Hospitals with multiple methods, there is no information on criteria
applied to method chosen.
Radiology (MRI Brain): Incidental Findings
North Tyneside and North Tees indicate that a 2 week wait referral is not suggested within
the report to the GP if an ‘incidental finding’ is found on an image.
A number of additional questions were asked regarding MRI scans and access to
neurological opinion.
+
GP Q9 – Counselling of Patients regarding potential findings
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Of those Practices with access to MRI scans, 75% indicated that responsibility for providing
counselling and information to patients around potential findings lies with the referring GP. A
single Practice felt this responsibility lies with the ‘hospital’ – presumably the Hospital
receiving the referral.
*
GP Q10 – 2 Week Wait referral made at same time as referral for test
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Of those Practices with access to MRI scans, two thirds indicated that a 2 week wait
neurology appointment is not initiated at the same time as referral for this test – only 2
Practices (less than 10%) indicated that this would happen.
*
GP Q11 – Access to urgent Neurological opinion for those Practices without direct
access to this test.
4
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4
Over 80% of those Practices with no direct access to MRI brain indicated that they can
access urgent neurological opinion if necessary. 9 Practices felt they do not have access,
but it is interesting to note that other Practices in the same area feel they do; this may be
due to poor communication.
+
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GP Q12 – Wait time for Urgent neurological appointment
!
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It is interesting to note that although access to urgent neurological opinion is acknowledged;
almost 60% of responding Practices either do not know how long a patient might wait for an
appointment or believe wait times are in excess of 28 days. Over 20% of Practices provided
no response – suggesting that wait times are not known. There is no corresponding Hospital
data to validate this – although referral on the 2 week wait pathway would ensure that
patients are seen within 14 days.
SUMMARY (MRI Brain)
6/10 Hospitals provide direct access for MRI brain. There are 3 Hospitals which do not and
one gave no response.
There appears to be inequity of service provision in the Sunderland area where 3 Practices
have an existing fund holding contract where other Practices in the same area have no
access to this service.
There appears to be a disparity in perceived verses actual service provision in North
Cumbria; one Practice reported to have direct access in West Cumberland Hospital, whilst
North Cumbria indicated no direct access.
Paper submission of requests was the most common form of referral.
Most GP Practices were unaware of current waiting times. Hospitals indicated a maximum
wait time of 14 days.
Again there appears to be a disparity between the Hospital and GP responses in relation to
accessing “signed/verified” reports; 7 Practices indicated 28 days against the Hospitals
responses of 5 days.
5/9 Hospitals provide electronic reports, however, some still rely on post or fax.
Of those Practices with no direct access to MRI brain, 80% indicated they can access urgent
neurological opinion if necessary, however 9 Practices stated they do not have access.
4
CONCLUSION
Due to the number of responses from primary care it is difficult to extrapolate with great
certainty the findings across NECN. From the data provided it is not always possible to
assess from which point counts are being made i.e. from date of referral or date of test. As
the questions in both surveys were not identical, results from GP Practices and Hospitals are
not directly comparable.
One key message from the survey is that direct access to specific diagnostic tests to
Radiology is generally available across NECN and GP Practices are aware of this service.
Several GP Practices would welcome support and education, in particular early recognition,
appropriateness of referrals, translation of diagnostic reports, spotting signs and making best
use of investigations/imaging.
GP Practices responded to say that paper submission of requests was the most common
which immediately causes a delay in the patient’s pathway.
It was noted that not all Hospitals have Anglia ICE System, (instant on-line requesting and
reporting system) particularly one which interacts with Radiology and enhances timely
requesting and reporting communication between secondary and primary care and removes
the need for paper requests. The implementation of the (Radiology) ICE system would
remove non value added steps within the patient’s pathway.
For those who do use this system (or similar systems) it is imperative for the
Radiology/primary care interface to interact on all levels in order for diagnostic results to
drop instantaneously into the referring GP’s mail box; replicating the Pathology/primary care
interface and therefore prompting immediate action. It was noted at a recent GP visit there
was a breakdown in this particular element of the Radiology/primary care interface
(instigating a less streamlined pathway with increased process steps, preventing a pull
system of information within primary care); the consequence of this equates to a longer wait
in the patient pathway. Consistent and effective IT systems have been raised as an
essential element to support speedy communications and decision making (NHS
Improvements Diagnostics 2012).
Analysis shows there is disparity in the actual and perceived times to accessing a
“signed/verified” report. Further investigation highlighted that many GP Practices would wait
for a hard copy paper report before further action is carried out; albeit a report is accessible
immediately on the hospital computer system which can be access by the GP.
Area of good practice – City Hospitals Sunderland and Primary Care worked together to
reduce the turnaround time of CXR reports from 15 days to 3 days and were able to
incorporated all plain film images with one process for urgent and routine alike. They
currently provide a same day reporting service for CXR, through the introduction of lean
methodology, reducing process steps with improved communication between primary and
secondary care as well as shared learning.
RECOMMENDATIONS
Raise awareness to GP’s and Practice staff of what Direct Access services are
available to their Practice along with waiting times.
Ensure referral protocols are easily accessible and adhered to.
Advocate the use of Anglia ICE - Radiology/primary care interface to fully interact on
all levels replicating the Pathology/primary care interface.
Promote accessing timely reports within primary care to remove delay – not waiting
for a hard copy paper reports.
Ensure the referral and reporting pathway is operationally lean removing non value
added steps.
Referrals - provide safety netting procedures (a guarantee of security) in both primary
and secondary care to capture those patients who DNA.
Regular flagging system to GP Practices of waiting and reporting times, (as these
can vary throughout the year) i.e. access ‘live’ report turnaround times within primary
care.
Work to be done on timely recall of patients following these tests.
MRI brain has been the most contentious of the direct access tests. This mapping
along with further discussions with the Brain & CNS NSSG and primary care is
require to agree Network guidelines
Further work on understanding how some of the wait times have been calculated in
order to understand apparent mismatches between Hospitals and GP Practices, i.e.
waits of over 28 days.
Ensure there is equity of service provision across the network.
Controversial – once Anglia ICE is available STOP paper requests and reports.
NEXT STEPS
Carry out flexi-sig mapping and determine service provision across the Network.
Mapping report to be discusses at the Cancer in the Community group:
o
o
o
Discuss and prioritise recommendations.
Consider joint working between the Cancer in the Community Group and
relevant NSSG’s, and agree how to take this project forward.
Develop an action plan.
REFERENCE
Department of Health, (2011) Improving outcomes: A strategy for cancer, London:
Department of Health
Department of Health, (2011) Direct Access to Diagnostic Tests for Cancer: Best
Practice Referral Pathways for General Practitioners, London: Department of Health
National Cancer Intelligence Network, (2010) Routes to diagnosis – NCIN data briefing,
London: NCIN
NHS Improvement Diagnostics, (2012) Supporting Direct Access to Diagnostic Imaging
for Cancer: Best Practice Pathways for Diagnostic Imaging Teams, Leicester:NHSID
ACKNOWLEDGEMENTS
The North of England Cancer Network would like to thank the following group of people for
their contribution to this document:
GP’s and their Practices
All Radiology Departments within NECN
APPENDIX
Key to abbreviations:
STDH
CHS
NCUH
GHC
NUTH
N’bria
STEES
NTH
CDDFT
CHS/GHC
HGH/GHC
NUFFIELD
South Tyneside District Hospital
City Hospitals Sunderland
North Cumbria University Hospitals
Gateshead Health Care
Newcastle upon Tyne Hospitals
Northumbria Health Care
South Tees Hospitals
North Tees & Hartlepool
Co. Durham & Darlington Foundation Hospital
City Hospitals Sunderland / Gateshead Health Care
Hexham General Hospital / Gateshead Health Care
Nuffield (Independent Sector)