Primary care leaders joined Pulse PCN editor Victoria Vaughan to discuss challenges and progress in early cancer diagnosis
Victoria: The early cancer diagnosis specification came into the contract in 2020. What has that meant for your PCN and how has it worked in practice?
Sarah Forster, Strategic business and transformation manager at Medics PCN, Bedfordshire
At Medics PCU we couldn’t have delivered what we have if I didn’t have a cancer lead that was clinical in my PCN and buy-in from my GPs. It’s a fantastic deliverable, but an awful lot of work. Obviously 2020 was a very difficult time. The specification was paused while many of us were doing vaccinations. But we worked well with system partners and Cancer Research UK (CRUK).
We asked our practices to complete an audit. From that we found that one of our practices had a really good approach, leading on the referral process. It was not a coincidence that the year before they had worked with CRUK. We set up a small task group of three GPs, who met every month to thrash out the best referral practice pathway. There are lots of other elements but that’s the biggest piece.
You need to take that time. It’s just not doable otherwise.
Dr Shanika Sharma, CD and cancer lead at Barking and Dagenham PCN, east London
I completely agree with Sarah. We were lucky that one of our GPs was the previous CCG cancer lead and did a lot of work with Macmillan, so she brought in a Macmillan cancer co-ordinator who helped to drive it by getting practice engagement, sharing resources and sharing data on cancer screening and how it looked at a practice level and at a PCN level. I know we’ve got data on Fingertips, but when you have someone who’s mapped it for your PCN and they present what the practices are looking like, it really helps.
We evaluated our safety-netting tool and found it was not as effective as we hoped. Soon after that, we had a clinical effectiveness group run by Queen Mary University London (QMUL) in east London. It developed a new safety netting tool that was rolled out across all the practices and put on all the clinical systems. It’s really helped drive the early cancer diagnosis. But without this system support it’s very difficult on an individual PCN level.
Dr Binodh Chathanath, CD at Bexhill PCN, East Sussex
We are a PCN with three large practices, so we identified three GPs to represent their practices as cancer leads and employed a cancer care co-ordinator. The cancer co-ordinator made links with the East Sussex Cancer Alliance and the Macmillan team and we did presentations to educate our clinical colleagues and the admin team about running searches, identifying people and inviting them to screening programmes. A key thing we did was to encourage one admin person from each practice to become cancer champions. They liaised with patients and made the connection between the cancer care co-ordinator and the practice. We hold a monthly meeting to discuss updates. We’ve improved a lot. At the beginning, there was a lot of chaos about doing FIT tests and not having blood tests together for the local trust.
Dr Baldeep Syan, GPSI oncology in Hammersmith and Fulham, west London
In terms of our PCN and the wider borough at Hammersmith and Fulham, being the cancer lead, I had the benefit of data. It is slightly older, I could go into meetings with each PCN and show them their position in the borough and the wider situation.
In terms of the PCN DES, I found it worked well to break things down for each practice into small manageable chunks with an action plan so it wasn’t overwhelming. Otherwise, you’re trying to boil the ocean with this big chunky piece of work.
One of the interesting things we did was significant event analyses (SEAs). They helped develop a community of practice in the PCNs. And they’ve helped change practice, with things like safety-netting and reviewing cancer diagnosis. A lot of good work has come out of that.
Dr Bal Dupa, CD at Oldham East PCN, outer Manchester
The PCN DES has started to focus our minds. Working at scale, working with other practices has been really useful. But we also have to be very critical of ourselves. The reality is the outcomes for our patients. Since the PCN DES came into place, [outcomes] have deteriorated. Health inequalities for cancer have got worse. If you speak to our secondary care colleagues, they’re very critical of primary care – and there may be reasons for it. They’re critical of the fact that we shut up shop. I speak to a lot of professors of oncology, who say, [some] cancers are now irretrievable. [They’re seeing] the late stages of cancer a lot more. That’s something my friends in oncology are really disheartened about.
Cervical screening was a big success for general practice over many years. Now something has changed – suddenly, people have lost confidence in coming to us to get smears done. We need to be critical of ourselves. Have we focused on the wrong things? Have we sat in rooms talking to each other, but not talked to people outside us? And [4.6 million people did not take up their latest test] – it hasn’t been good enough because they’re not coming forward.
Being critical about the PCN DES, we’ve become very insular in how we’re looking at cancer. Yes, we’re talking to Macmillan, but not to people who are commissioning cancer care. Very few of us are having good conversations at scale with oncology departments, cancer trial patients and people who are commissioning the screening procedures. Our cervical screening and breast screening programmes are commissioned at a national level. We haven’t got any traction in those conversations so far.
Shanika These points are really important. Our cervical screening rates in Barking and Dagenham were historically lower than the national average anyway. But, during the Covid pandemic, we noticed they were dropping even further. We got together as a PCN, and made some videos in different languages, to target hard-to-reach populations – people from Asian or Eastern European backgrounds. We did videos in many languages and encouraged practices to send them out.
The link with health inequalities work is really important. We’re currently working with our public health partners. We put a bid in for health inequalities money across Barking and Dagenham. One of the projects aims to encourage breast screening in elderly patients, and to explain to them the importance of breast screening. The proactive approach for cancer screening has been identified as a priority in our borough-wide partnership. I agree this must be done outside the PCN. It has to be across the board with public health at the local authority, with secondary care, with community services all on board.
The SEAs also identified that some things are beyond the control of primary care. It identified a lot of problems with diagnostic pathways. There were patients who were referred for a CT scan by primary care, but never had the scan, or it wasn’t safety-netted.
Binodh Bal, this is exactly what we are thinking about. We have extended our hands towards the commissioners, the secondary care cancer delivery manager and the CRUK team. We have a quarterly meeting with all of them, and that’s when we have the SEAs and discuss difficult cases. This has helped improve relationships between each of us. Now, through the cancer champions, the secondary care managers have access to the practices. We’ve asked them not to reject referrals, and if they need more information, the champions provide it. Sometimes we have to go outside the specifications, but at the end of the day, these small things make a big difference later on.
Sarah I’m interested to see what people think about the impact of telephone triage over the last three years. Are things not being picked up because patients aren’t being seen face to face?
Bal There is a concept in primary care that ‘every contact counts’. We say ‘Yes, I know you’ve come for your ear infection, but do you realise it’s really important to have your smear?’ I think there is a distance growing between primary care. Maybe we need to re-evaluate.
In our practice, which is in a very deprived area, our screening rates were very good but they dropped off. We attributed it to telephone triage. We’ve gone back to fully face-to-face appointments, and guess what? Our screening and vaccination rates are coming up because you remember ‘the contact counts’ and the doctor has a pastoral role.
It’s been a conscious decision to view the triage machine as another tool rather than a replacement, which is how it was viewed in Covid. Seeing your patients does reduce health inequalities. That’s a reality. We know that.
Binodh We also are reducing our use of telephone triage. We are going face to face. And nurses have never stopped seeing patients face to face – neither did healthcare assistants. A really small number of people have telephone contacts. Our chronic disease monitoring has gone down a bit, but it’s picking up. [Those face-to-face contacts are] an opportunity to emphasise the importance of all these screening programmes.
To improve access, we have set up a group of three nurses who are offering extra sexual health sessions for women at weekends. There’s at least one clinic every three weeks, from 9am to 1pm, where women can drop in or make an appointment. Improving access is key.
Sarah My cancer lead’s practice has completely switched back to face-to-face appointments. But our PCN has five practices that all work in their own way, as does each clinician. There are various members of PCN staff such as paramedics and physician associates who are predominantly working by telephone triage, so we can’t change that.
Baldeep Public health in England needs to play a role in this as well, in raising awareness. I read a statistic the other day that a full-time GP will have eight or nine cancer cases diagnosed in one year. It’s not a lot if you think cancer’s going to be present in one in two people. We need campaigning for patients to be aware of what red flag symptoms are, when to present to their GP, why we do screening, and what the purpose of screening is. I don’t think there’s enough at the moment.