Recognition and Referral of Suspected cancer NICE NG12 – 2Week Wait Dr Katie Elliott Assistant Clinical Lead CRUK Strategic GP Northern Cancer Alliance Macmillan GP NE&C Learning Disability Network

2 Week Wait NHS measures trusts against the Cancer Waiting times standards. One of the measures is: a maximum two-week wait to see a specialist for all patients referred with suspected cancer symptoms

10 Acute Trusts >400 GPs 12 CCGs 12 tumour groups

NEW GUIDANCE - Recognition and referral for suspected cancer NICE NG12 Identify more cancer at an earlier stage Symptoms based Early referral/ direct to test in primary care BLOOD TESTS/ CXR/ CT/ MRI Minimum Positive Predictive Value 3% Implications for referral pathways Impact on diagnostic services Impact on patients and systems

Investigations or referral for suspected cancer Recognition and referral for suspected cancer - NICE NG12 Symptoms in children and young people Investigations or referral for suspected cancer Cancer site Symptoms Investigation results Safety netting Information and support for people with suspected cancer and their families

Primary Care – Urgent tests Bloods FBC within 48hrs CA125 PSA U+E, Coag screen/calcium/Plasma electrophoresis/ESR CXR 48hrs Plain x ray 48hrs USS 2ww CT 2ww MRI 2ww Understand the importance of timely access to blood tests in primary care Unexplained bruising, lymphadenopathy, pallor women > 50 with sx of Ovarian cancer PSA -can be done same day as PR examination U+E - not specified in NICE but essential for direct to test for CT / Colonoscopy/ Lung/ CXR – be aware of your local escalation pathway - Chris to discuss more later USS/ CT/ MRI – 2ww drop down option available in ICE - use it but be clear about the criteria and U+E required

Secondary care - urgent clinics One stop clinics Breast Neck lump Colposcopy Gynaecology Hospital needs: Correct information on the referral form. Blood test results Communication needs and reasonable adjustments Straight to test Upper GI- CT/ Endoscopy Lower GI- CT/ Endoscopy Lung- CT/ Bronchoscopy Patient needs

Opportunity to develop standard, region wide referral forms Benefits One form for all practices to all trusts for each tumour group Up to date criteria. Only one form to change if guidance changes Link with GP IT system Facilitate straight to test Move away from hand written forms/ fax Concentrate on clinical narrative and criteria for referral Reduce risk of delay due to wrong form/ wrong information

Development Work with the Expert Groups Cancer managers Cancer Nurse Specialists Cancer in the community group – locality leads Improving Referral Forms Through Collaborative Working – Gateshead Team Dr Forbes NECS Detailed review of guidance Review of existing referral forms

Success? YES…. Single form for each speciality agreed Standard lay out Information merged from GP clinical system All GPs have access Mostly working ok BUT……. Difficult to use in hospital Visibility of information Relevance of information Incomplete information- performance status Still some work to do.........

Key learning from the review: Generic changes to forms improve lay out and function One stop clinics and straight to test need accurate information. Some triaged within 24 hours, blood tests must be taken ON day or BEFORE the referral is sent Incomplete information - can cause delay Clinical information and performance status completed by referring clinician Help primary care understand the importance of the information on the referral form Survey went out to all practices, trusts, booking teams – 371 responses. 80% primary care. Mostly working in primary care. Very lengthy forms and variable quality and completeness in secondary care. Clear issue about forms being completed by non clinicians - performance status and reason for referral often incomplete These forms are now one o the key tools to being able to streamline services getting patients straight to test before being seen in clinic or getting tests done in ‘one stop’ clinics. Incomplete forms may delay the journey for your patient. There are 2 main areas for completion – reason for referral and performance status where requested. Additional boxes about some drugs also required in EMIS.

Information and Support for patients and their families Tell people they are being referred/ investigated for suspected cancer. Explain what to expect from the referral/ investigation. Make reasonable adjustments - consider written information. Most people referred urgently will not have cancer. Secondary care team still concerned that people are coming in unclear about why they have been referred Use the word cancer Easy read leaflet soon to be available - has had input from LD groups and Alzheimer's society.

NE & C Learning Disability Network + Northern Cancer Alliance Julie Tucker Easy read version of the National standard patient information leaflet Gateshead People Alzheimer's society

Easy Read Patient Information The easy read PIL for each trust is now available on the Northern Cancer Alliance website.   http://www.necn.nhs.uk/networks/cancer-network/supporting-primary-care/ Please promote this to people and GP practices in your area and support us in making services more accessible.

What is safety netting? Management of clinical risk I am not worried today but if this happens… When should I come back to see the doctor? Management of organisational risk How do I know this process works? What is the back up plan?

Top Tips to take away… What are the top three tips you will take away from today? How will you use them within your practice? Who will you share this learning with in your practice? CRUK Safety netting booklet Macmillan Top Ten Tips Safety netting read codes

Resources Northern Cancer Alliance Website http://www.necn.nhs.uk/networks/cancer-network/supporting-primary-care/ NICE https://www.nice.org.uk/guidance/ng12 CRUK health professionals page - http://www.cancerresearchuk.org/health-professional Macmillan – Ten top tips – safety netting, Easy read materials, rapid referral advice http://www.macmillan.org.uk/Documents/AboutUs/Health_professionals/ RCGP e-learning free to members - early cancer diagnosis module GP Update/ MB Medical - cancer update courses