1. Session for Action: 2WW forms
Dr Esther Appleby
Macmillan GP, Lewisham

2. Pan-London NG12 Approach
Forms that integrate with all IT systems
Moving towards all electronic referrals (no more fax)
Hospital directory at top of each form
Check boxes for safeguarding concerns, mobility, sensory issues
Hyperlink to guidelines within the form
Auto-populate information from the record
Bloods
Imaging reports
Guidance/prompts within the form where needed
Patient information leaflets – translated into 11 languages
The new forms are available across all 4 IT systems: Emisweb, Vision, Integrated and non-integrated SystmOne
Concurrently there is a drive to remove fax as a method of sending referrals due to patient safety and confidentiality risks
We recommend ing referrals or using the e-referral methods (formerly known as Choose and Book)
TCST are supporting CCGs and trusts to setup a safety netting system whereby practices are notified electronically to confirm appointment allocation on receipt of a referral.
IMPORTANT: AT THE TOP OF EACH FORM IS THE WEBLINK FOR ALL THE TRUSTS ACROSS LONDON AND THEIR AND CONTACT INFO; THIS DATABASE IS UP-TO-DATE AND MAINTAINED BY TCST. IT IS ALSO BESPOKE FOR EACH TUMOUR GROUP AS NOT ALL TRUSTS HOST EACH SERVICE. Simply copy and paste the address from this website.
The new forms are indeed longer HOWEVER they are more useful especially with respect to communicating holistic aspects of the patient that will impact straight-to-test pathways. There are check boxes for safeguarding concerns, mobility, cognitive and sensory impairment(s)
The forms auto-populate clinical information including blood and imaging reports.
Each form contains several links to: referral guide, clinical guide, safety netting guide, patient information leaflets (11 languages), a bespoke breast and colorectal leaflet,
For example if you can not recall the age-specific PSA thresholds whilst on the Urology form you can click on the urology tumour group guide form within the form as a reminder.

3. NG12, 2015
Updated NICE NG12 (2015) IS based on primary care data, specifically symptoms
Positive Predictive Value thresholds have been lowered from 5- 10% to ≤3%
Urgent and non-urgent direct access investigations
Pan London approach involved over 100 clinicians including primary and secondary care across the capital.
Pan-London referral criteria is consistent with NG12, with a few deviations and retention of past criteria from 2005 and other tumour groups guidelines
Visit the website: london/cancer/pan-london-suspected-cancer-referrals
NICE NG12 Suspected cancer: referral and recognition was published in May Ten years ago CG27 was published by NICE which formed the basis for two-week wait forms across London.
The new guidelines are based on primary care data and are symptoms based.
The guidelines from 2005 recommended investigating symptoms with a positive predictive value of 5-10%
The new guidelines have lowered the threshold to ≤3%
There is an emphasis on the use of direct urgent and non-urgent investigations
The Pan-London forms were developed by TCST, London Cancer Alliance and London Cancer.
A patient participation group was also involved to ensure we addressed their views; this was particularly important when it came to the patient information leaflets for breast and colorectal referrals.
On the whole the Pan London suspected cancer referral criteria aligns with NG12 however there are a few deviations which are covered later on in the slide deck
WEBPAGE: Houses all the new forms across all 4 IT systems, an FAQ page, clinical guides and support documents

4. Pan London Deviations from NG12
· Breast has retained unilateral non-cyclical breast pain persisting for one than one menstrual cycle as a criteria for suspected cancer referral
· Children and Young People has retained current clinical practice of same-day referral and specialist assessment where NG12 states ‘consider an immediate referral (within 48 hours) or very urgent full blood count
· Colorectal GP access to FOBT has not been agreed but GPs have access to straight to test colonoscopy or CT colonography for this cohort of patients
· Gynaecology has lowered the threshold for suspected ovarian and endometrial cancer to 45 years and recommends concurrent CA125 and urgent pelvic and abdominal ultrasound
· Haematology has agreed to define ‘persistent bone pain’ more clearly and add ‘bone pain that has persisted for over six weeks’.  It has also been agreed to lower the age threshold for patient with suspected myeloma from 60 to 40 years
· Lung has retained ‘chest/shoulder pain and included ‘persistent chest symptoms suggestive of lung cancer despite a normal chest x-ray’
· Sarcoma includes GP direct and rapid access to x-ray and ultrasound but if a GP suspects bone sarcoma this should be referred to one of the three sarcoma specialist centres for London
· Urology uses BAUS age thresholds

5. Does not meet NG12
Each form has a box for GPs to refer where patients do not meet criteria but where a GP has a suspicion of cancer.
A study in Denmark revealed that GP intuition can be as accurate as using clinical criteria (25% cancers detected based on gut instinct)
NG12 has allowed this new feature and Pan London despite some hesitation have agreed to comply however this relies on GPs not abusing the service and using the ADDITIONAL CLINICAL INFORMATION BOX to justify and detail reasons for referral

6. Electronic referrals No more fax!
Please either referrals or use E-referral system
At the top of each form sits a live link with the latest hospital contact information
Also bear in mind it is form specific as not all trusts provide all cancer services
We have kept fax details for head and neck providers only to allow dentists to refer – this will hopefully change in the near future

7. Safety netting SAFETY NETTING IS KEY
COMPLETE AND ACTION THIS SECTION (SEE IMAGE)
Please counsel the patient regarding the referral process and offered the pan-London information leaflet. Offering a written patient information increases patient experience and reduces non-attendance. These are available in 11 different languages.
Within each form is a top ten tips for safety netting and patient information leaflet weblinks
Please ensure you have a safety netting system that is fit for purpose
TCST will be releasing some advice on electronic safety netting for all IT systems in order to support practices to implement robust systems for safety netting. EMIS web and Vision daybook can facilitate safety netting simply and reliably.
We also ask that you complete the referrals and provide all necessary investigations that are pending. The forms are coded and should autopopulate blood and imaging results however it is essential you check this.

8. Audit and future plans
The next audit of 2WW forms is to take place in April
Questions should be directed to… [contact details]