Read part one of our blog on understanding the single cancer pathway here.
Getting it Right, Right at the Start
Consistent with a core element of Welsh Government’s, Wales Cancer Delivery Plan, the new single cancer pathway is designed to be patient-centred in every way. As over 90% of all cancer patients will first visit their GP with symptoms, the relationship between the GP and patient is paramount if the single cancer pathway is be efficient and ultimately succeed.
It has long been felt that a greater awareness of cancer symptoms among the general public is needed. While this may certainly still be case, at least for some cancers, it only paints part of the picture. Awareness campaigns run via the media and through various other healthcare channels are important ways of communicating cancer symptoms, and while no-one would question their value, the impact they have is often limited and transient in nature.
Recent evidence from the ICBP4 study indicates that bowel cancer patients in Wales take longer to act on symptoms. Moving forward, a better understanding of the health-seeking behaviour of the population will be needed as well as encouraging people to take more responsibility for their health. With help and support from the various health organisations, primary care offers the greatest opportunity by which this can be achieved.
Historically, GPs are seen as providing a gate-keeper role for the health care services to help ensure that resources are used efficiently. However, gatekeeping is associated with delays in cancer diagnosis and adverse outcomes, and is something that negates the patient-centered approach to cancer care. These difficulties are further complicated by the non-specific nature of cancer symptoms. Of the all patients who do visit their GP with suspected symptoms of cancer, most will be found not to have cancer.
The single cancer pathway will seek to provide support for primary care teams by delivering tool kits and support systems that will help improve decision making in line with the latest cancer symptom referral guidelines issued by NICE. However, all decisions should be jointly shared by the patient and GP, following careful explanation and consideration of all the risks and benefits. The advantages of this are many, not least avoiding over-diagnosis and over-treatment for some cancer types.
There are existing challenges that will need to be overcome. These include the training and retaining of GPs to meet the current shortfall in Wales, and better patient access to primary care. Recent news stories have claimed that many patients have to wait over 3 weeks before they are able to see a GP. When an appointment is eventually made, the limited time that a patient has to spend with a GP may make people more reluctant to chase an appointment in the first instance.
The GP-Secondary Care Interface
One of the major barriers that hinders early diagnosis is the complicated nature of existing cancer pathways, and the different avenues by which patients can enter secondary care for investigations. Clearly articulated referral pathways that give GPs easy access to secondary care for the different cancer types is vital, as this nexus is one of the most crucial in the single patient pathway.
Many cancer symptoms are often vague and do not conform with bona fide red flag symptoms, although may be enough to cause concern. This dilemma is one of the most confounding issues for early cancer diagnosis in primary care. This all looks set to change as a result of the newly established Rapid Diagnostic Centres in Wales which provide a one-stop shop where GPs can refer patients to have all the necessary tests undertaken within a matter of days, and a diagnosis made shortly, thereafter.
Two centres are currently being trialled, one in Neath-Port Talbot and one in Cynon Taf. Early results have so far have fully justified their introduction, and if permanently expanded across Wales, the Rapid Diagnostic Centres will form an essential component of the single cancer pathway.
The implementation of tracking systems will allow GPs to closely monitor and follow the patient as they journey through the single cancer pathway. This provides a safety net to capture patients and ensure they are not lost in the system if a cancer is not diagnosed initially, and facilitates the prompt signposting to the correct department if something other than cancer is discovered.
Increased Workforce, Equipment, and Better Linked-Infrastructure
For the single cancer pathway to work effectively, an investment to boost diagnostic capacity is urgently needed. Work commissioned by the Wales Cancer Network has reported an increase in resources by at least 20% will be required during the initial phase, followed by a further 10% per year for the next few years following implementation. A lack of equipment, trained specialists, and an ever increasing demand for services, are just some of the recognised problems that have led to bottlenecks in the current system.
These issues cause delays in the time taken for investigative procedures such as colonoscopy, biopsy sampling, and various scans such as CT and MRI. It is noted that several health boards in Wales do not have the necessary scanners needed to undertake multi-parametric MRI for suspected prostate cancer. This new technique can diagnosis prostate cancer with greater accuracy than ever before, while at the same time avoid the need for more invasive biopsy which can have lasting troublesome side effects. PET is an advanced imaging technology that is increasingly used for cancer detection as it can pick up small clusters of cancer cells that other conventional scans may have missed. Unfortunately, Wales is home to only one PET scanner, compared to over 75 that are scattered around the rest of the UK.
Screening will form an important component of the single cancer pathway, sitting alongside GP referrals for symptomatic patients. Next year, the introduction of a new and more sensitive screening technique for bowel cancer, combined with lowering of the age at which screening will start (50 from 60), will add even more pressure on a system that is already at breaking point. Presently, there are only 18 registered screening colonoscopists, and 20 endoscopy specialist nurses in the whole of Wales. Also some health boards are faced with a serious lack of space in which to undertake these procedures.
Pathology is another critical component of the single cancer pathway that is currently under-resourced. It is estimated that up to 1 in 5 posts in Wales remain vacant. Since pathologists determine the presence of cancer in biopsy specimens following endoscopy or radiology, a well-equipped pathology workforce is essential if the single cancer pathway is meet its aim of diagnosing cancers more quickly. Extra equipment and trained staff for endoscopy, as well as recruitment of specialist doctors in radiology and pathology will all help facilitate the rapid and seamless flow of patients along the single cancer pathway.
Welcomed moves have recently been made by Welsh Government to address some of the infrastructural issues. These include regional investment for extra endoscopy suites and day surgery facilities in North Wales. Also the establishment of an All-Wales Imaging Academy by Welsh Government will help attract newly qualified doctors to radiology, a specialty that has seen a decline in numbers due to an aging workforce reaching retirement age. At the Academy, the next generation of radiologists will receive standardised training using the very latest cutting-edge technologies.
Intelligence, Systems, and Information Technology
The collecting of information from the various health boards in Wales will be essential to assess what systems already exist to support the single cancer pathway and to identify areas where extra resources are needed for it to become fully functional. This will include the gathering of data for all the major tumour sites, and importantly the forecasting of what capacity will be needed for the future. Creating an evidence base which informs how the single cancer pathway should be built is an essential forerunner to any monetary investment.
New data systems on which all the information can be easily stored and retrieved will be critical as CANISC the current system in operation in Wales, is no longer fit for purpose. Whether it is baking a cake or constructing a car, the quality of the vital ingredients is what defines the excellence of the final product. Therefore, a standardised way of harvesting and collating information should prevent such systems from becoming polluted with poor quality data.
Although not insurmountable, challenges will be faced given the low baseline from which Wales will be starting with respect to capacity and resources, all which so often affects the moral of hard-working, conscientious, yet overstretched staff. To ensure the delivery of the single cancer pathway, regional Health Boards will need to take responsibility, driven by empowered leadership at the executive level, and combined with nationally driven accountability to Welsh Government – not to mention the role that third sector, patient groups, and other stakeholders have in making this bold ambitious plan a reality.
In the next blog we will discuss how research may help continually improve and drive the performance of the single cancer pathway.
blog written by: Dr Lee Campbell