At the end of November, Health Minister Vaughan Gething, announced radical plans to transform the way by which cancer patients in Wales are referred for diagnosis and treatment. A new single cancer pathway in Wales is set to replace the two tier pathway currently in operation. This ambitious, yet very welcomed move, is aimed at cutting waiting times for all cancer patients, improve early diagnosis, and further increase patient satisfaction. In this series of blogs we will share some of the issues with the current system, what the single cancer pathway represents, what will be required to make it work effectively, and finally how research can help with its construction.
The current issues
It is well known that Wales suffers from relatively poor cancer survival rates compared with many other countries, especially those with similar healthcare systems. Although survival rates are steadily improving, the gap between Wales and the other countries still remains as wide as ever.
It is thought that one of the major reasons behind these worrying statistics is that we simply diagnose cancers too late. However, the speedy diagnosis of cancer is anything but simple, and there are many factors that influence the time it can take to detect and treat the disease. One prevailing concern is that the structure of the existing cancer pathways in Wales are too long, too complicated, and too convoluted, that when compounded can add significant delays to the whole diagnostic process.
The urgent cancer pathway
Currently there are two ways of referral for cancer patients in Wales. These are known as the urgent, and the non-urgent cancer pathways. GPs will refer patients via the urgent cancer pathway when they see obvious red-flag cancer symptoms in patients, or other signs that should be acted upon as recommended by the recently overhauled NICE cancer referral guidelines for primary care. When cancer is suspected, and patients are placed on the urgent cancer pathway, treatment is expected to start within 62 days if cancer is confirmed.
There are a number of confounding issues that directly impact the urgent cancer pathway, all of which may adversely affect the rapid diagnosis of cancer in patients. Firstly, it is not fully known how many GPs strictly adhere to the current NICE cancer referral guidelines. This is a searching question that is being researched as part of the Cancer Research Wales programme that focuses on cancer diagnosis in primary care.
Secondly, there is evidence that some urgent referrals made by GPs are down-graded to non-urgent by consultants in secondary care. Unfortunately, this has led to some high-profile cases where patients have received a diagnosis of terminal cancer after first entering the system via the urgent route and then having to wait a long time before being seen. It is acknowledged that secondary care consultants also upgrade some non-urgent cases if cancer is strongly suspected from the clinical notes. Reassuringly, all these contentions will be removed once the new single cancer pathway is introduced.
The non-urgent cancer pathway
The non-urgent cancer pathway is the route by which approximately 60-70% of cancer patents are currently diagnosed and treated and so represents the area where the greatest changes will be seen when the single cancer pathway is introduced. The non-urgent cancer pathway refers to the route taken by patients who may present to their GP with problems not initially recognised as typical red-flag symptoms, or other warning signs that do not strictly align with the current primary care cancer referral guidelines. As is common, a lot of cancer symptoms are often vague and also occur in many other more prevalent, less serious conditions (as do most red-flag symptoms). As a result patients are often referred to secondary care departments for investigations for suspected conditions other than cancer. Alternately, patients may be diagnosed with cancer following a visit to A+E.
When patients are finally diagnosed with cancer via the non-urgent route they are expected to start treatment within 31 days. The greatest problem has been that many of these patients may have already wandered within the labyrinth of the health care system, for very long periods. During this time, patients may have visited their GP on numerous occasions, accompanied by multiple appointments within various hospital departments, before cancer is diagnosed.
The new single cancer pathway
Essentially, the single cancer pathway sets out to merge both the urgent and non-urgent pathways with one standardised waiting time of 62 days. The 62 day target starts when a suspicion of cancer is made by a clinician. The reality is there will be little obvious change when compared with current urgent pathway.
However, with GPs now placed in charge of the starting gun in most instances, the single cancer pathway will be unrecognisable from the current non-urgent cancer pathway and should be quite transformative with the potential to greatly reduce overall waiting times for all cancer patients across Wales. It is hoped that 95% of all cancer patients in Wales will be diagnosed within 62 days by the summer of 2019. Further, it is anticipated that for some cancer types, where the diagnostic journey is more straightforward, a diagnosis could be achieved within a month – which is great news.
The envisaged benefits of a single cancer pathway
The chief aims of the single cancer pathway are reduced overall waiting times, early cancer diagnosis, improved patient experience, and provide a vehicle by which to continually drive improvements in service delivery. This should allow gaps and bottlenecks in the system to be more readily identified, with a quicker mobilisation of resources to the areas where they are needed most. A single cancer pathway will also confer greater transparency, accountability, and help establish better links both within, and between, Health Boards across Wales.
Reduced patient anxiety as a result of prompt cancer diagnosis and treatment, safety netting that provides follow up – and in the case of an all-clear – referral to the more appropriate departments and speedy treatment for other non-malignant disease, are perhaps the biggest benefits that a single cancer pathway will bring.
In the next blog, we will consider some of the resources that will be required to make the single cancer pathway work effectively for all.
Read part two of our understanding the single cancer pathway blog here.
Blog written by: Dr Lee Campbell