Hi Iain, I am a GP and feel the Labour are misrepresenting the situation regarding the ‘right to see a cancer specialist within two weeks’. As you say, the inference of their campaign is that patients will be disadvantaged should this target be removed and that their health could suffer. In the PPB tonight, it had an anxious patient saying: “But I don’t have time!”, the inference being that he may be beyond helping if he waits more than two weeks. This gives a very inaccurate representation of the facts – indeed I wonder if the ASA could be asked to investigate the message behind this PPB and the campaign leaflets which give the same inference?
The truth is, the effects of this target have been analysed and found to have achieved the opposite effect. Various medical journals have researched the impact of the 2 week wait and have shown it to be counterproductive. This is for the following reasons:
• The majority of people eventually diagnosed with cancer do not meet the strict referral criteria for the 2 week wait – and they are having to wait even longer because of the 2 week waiters taking priority.
• In addition, the wait for results of diagnostics, scans etc and the clinic appointments to discuss them and the start of treatment are also waiting because of the priority for the 2 week wait.
• The main delays in cancer treatment occur at the following stages: 1/ delay between getting symptoms and deciding to go to the GP; 2/ delay between the initial 2 week appointment and the commencement of treatment. The time between the GP referring and the patient being seen are much much less than these times.
Other problems, directly due to Labour government interference are: 1/ the 2 week wait doesn’t allow sufficient flexibility to refer to the consultant of the patient’s choice; indeed because of this new pressure on referrals sometimes the patient is seen by a lesser qualified nurse-practitioner and doesn’t get to see a consultant at all – it is too soon yet to know if this is fully safe. 2/ the constraints on prescribing cancer medications for patients who are incurable or resistant to other treatments (imposed by NICE).
As GP I can tell you that cancer care is an important issue to people and it is true that the 2 week wait is popular as patients understandably worry if the GP refers them because of a risk of cancer. However, more needs to be made that Labour’s populist approach to this very small aspect of the patient experience is not the key thing in what matters: ie getting the patient swiftly treated with a high chance of cure.
Like the present conservative thinking, I feel a greater emphasis needs to be on OUTCOMES (and this applies to all public services), rather than just shovelling money and the unevidenced targets which might well be populist, but ultimately ineffective.
Hope you find the links below useful. And do keep blogging!
Regards,
XXX
Telegraph: Women with signs of breast cancer wait months as Labour breaks manifesto pledge.
And THIS which starts with: “Women with suspected breast cancer are being failed by the Government's waiting time target and it should be scrapped, doctors report today.”
Some relevant studies can be found in: the BMJ.
“The ‘two-week wait rule’ is failing breast cancer patients” “the researchers found the percentage of patients diagnosed with cancer in the 2-week wait group decreased from 12.8% to 7.7% whilst the number of cancers detected in the ‘routine’ group increased from 2.5% to 5.3% over the same time period. In 2005 more than 1 in 4 (27%) patients ultimately diagnosed with cancer in 2005 was referred non-urgently. Dr Potter describes the increase in cancers diagnosed from the routine population as “alarming” and says: “These patients are also potentially being disadvantaged by longer clinic waits and delays in diagnosis as waiting times for routine referrals have increased in the face of increasing service demands from the dramatically increased number of patients referred under the two week rule, over 90% of whom have benign disease.”
And another from the BMJ
- showing only a tiny minority of gastric cancers are picked up by 2 week wait – the majority are found at ‘routine’ endoscopies. (implies the target not helping those most at need)
And yet another from the BMJ
- the conclusion in this paper includes: “The two week standard clinics did not shorten the overall time to treatment or improve the stage of disease because the time lags before referral and after the outpatient appointment are the major causes of delay in the bowel cancer patient’s journey”.
A review in the BMJ of the same paper noted: “Although patients referred to the two week clinics were seen more quickly than patients referred elsewhere, they were not treated any more quickly, nor was their disease caught earlier, the audit showed. Furthermore, referral to a two week clinic had little impact on the length of time patients had to wait for treatment, nor was their disease caught at an earlier stage. This was because the time lags before referral by the family doctor and after the outpatient appointment, which are the major causes of delay in bowel cancer treatment, remained the same. The government should not be deterred from stumping up more money to ensure that all patients with bowel symptoms can be seen promptly, say the authors. But the two week urgent referral is being let down by delays elsewhere in the system. “Ultimately the value of the two week standard is small in the context of a process of care that is slow both before referral and after being seen in outpatients,” they comment.
And THIS...
“resources may be more effectively targeted at reducing the waiting times from diagnosis to treatment than on reducing the time from referral by a general practitioner to diagnosis”.
And finally from the BMJ.
I don't think any comment from me is necessary.
20 comments:
Anyone know where 'Noelinho' went to?...
I was out with a doctor this evening. He said that people in the NHS don't like targets much so Gordon will have lost another bunch of votes as a result of the PPB.
Turning to the promise, he said that it's all very well, but what will they fail to deliver as a result. He didn't think that it would improve outcomes.
Iain, just thought you'd like to know about Jonathan Bartley who ambushed David Cameron earlier today with his disabled son. The BBC are trying to portray him as a "angry parent" but Bartley is the co-director of a liberal Christian think tank called Ekklesia. He's certainly no ordinary passerby. He's appeared on a number of Radio 4 discussion programmes such as "The Moral Maze", so he must be known to the BBC so their news items are disingenuous.
He's also written for the Guardian, Independent and The New Statesman. In his latest article on Ekklesia's website, Bartley hypes up the LibDems as the "party of hope".
It looks so much like it was a politically motivated ambush.
Bang on. I just wish this could be wrapped up into an equally populist counter-message to rebut Labour's scare tactics.
I'm here. I was merely asking a question - and I'm really not worth wasting time over.
I think this is the issue that makes me angiest of any in this election. I did a little personal story to explain why here:
http://theviewfromcullingworth.blogspot.com/2010/04/cancer-how-two-week-target-is-nonsense.html
Despicable lies from the LDs and from Labour. Perfect coalition partners.
Meantime over on the ever reliable WUWT it seems Austrilias labour PM has junked his carbon trading election manifesto committment.
http://wattsupwiththat.com/2010/04/27/australia-dumps-carbon-trading-scheme/
This is all very well, but whether you measure outcomes or performance against targets, you are still trying to control a massive organisation from the centre. Until the NHS is broken up and reformed, people will go on dying unnecessarily, whether the NHS measures itself against a 2 week waiting target or measures itself for cancer death rates.
Thanks for this very interesting item, which I see comes with links so that we can inform ourselves about the ins and outs of this complex topic.
I used to work for the Royal College of Radiologists [which includes the radiotherapists] so I know how emotive and how deceptive arguments about delays in diagnosis and treatment can be.
If your cancer, which is several years old by the time it is diagnosed, has already spread then it is likely to kill you [it won't if you die of something else first]; if it hasn't, then it is unlikely to spread while you wait for diagnosis and treatment and surgery + radio- + chemo-therapy has good chance of killing it first.
We live in France. My wife had a positive result to a standard 'poo test' and received a letter by return of post to see her doctor which she duly did on the same day. The doctor arranged for an appointment the following day with a consultant who arranged for a coloscopie examination. He also made an arrangement for her to see the anaesthetist while she was at the clinic. Less than 2 hours after her arrival at the clinic she left with a date for the examination to be carried out under full operating theatre conditions a couple of days later.
The examination revealed a polyp and a date for its removal was made within hours of finding it. A couple of days later the polyp was removed at the same clinic and sent for further examination. However, the surgeon was clear that he had removed the polyp and surrounding tissue and could see no further evidence to be concerned about. All this took less than a week!
When the results of the tests on the removed polyp came back, they showed the polyp to be malignant. So, although they were content that there no visible evidence of cancer remained, a 6 month course of chemotherapy was recommended as 'preventive' measure. Having completed the course she was re-examined by coloscopie and found to be 100% clear.
This entire event was conducted with speed and efficiency and the word 'wait' or 'waiting' or 'waiting list' or 'government target' were never mentioned or even hinted at. There was never any doubt that my wife was going to be given the best of treatment and without delay.
One of the contributors to the lack of any delay was the way which examination results are managed. The results of all X-rays, scans, ultrasound examinations, blood tests and the like are produced and given to the patient immediately afterwards. There is no waiting while the results are sent to whoever commissioned them. The patient takes the results back themselves. The patient is trusted to hand-carry the results. This way a lot of the delays incurred just don't happen.
Anyway, since France has an almost identical population to the UK, I can't help wondering quite why the UK seems to have so many problems with the political football that is the NHS whilst here things seem to work so much better, quickly and without all the agonising and hand-wringing that accompanies just about anything to do with the NHS.
Time for a serious re-think about how the NHS works particularly quite why the delays which seem to be built-in to the way things are done. It may just be that it's not money, God knows the NHS gets enough of that. It may just be that a basic review of the time-honoured system that keeps that patient at arm's length from the doctor would reveal the real cause of the emotive delays that give rise to so many problems.
Could your GP correspondent provide figures on what percentage of cancer diagnoses arise from initial referral for something else? This was true in my own case six years ago. I was on a long waiting list to see a consultant (thanks Labour) and, because I was in discomfort, chose to see the consultant privately to speed things up. Whilst undergoing treatment for something believed to be non-malignant, a biopsy revealed cancer. When a GP suspects cancer, no-one hangs about and patients are referred quickly. No target is needed. The problem is how long it takes to see a consultant when cancer is not initially suspected but is nonetheless there.
A related pledge is that the results of all "cancer" tests will be back within a week. Even if you look at the simplest of these tests, a PSA blood test screening for prostatic cancer, the logistics of ensuring that every, not just 90%, result is back within a week are challenging. Meeting that pledge will distort the priorities of the service with no benefit to patients. When the investigation is a more complicated one, using very expensive kit, the effects of a mandatory 1 week turn round time will be even more deleterious to the service as a whole.
What worries me is that the two medical royal colleges most involved in diagnosis, The Royal College of pathologists and the Royal College of Radiologists, have been silent on the consequences that would arise from the mandatory implementation of this pledge.
It's very simple. The whole technique behind the whole Blair Brown 'project' has been been spin aka lies. Everything, but everything they say should be taken with a very large pinch of salt. Somehow people jhave to be made to understand that New labour has nothing whatever to do with better governance but all to do with maintaining in power and enriching the likes of mandleson and Blair and providing highly paid 'jobs' for unemployables like Cooper and balls. It's just a deceit machine. And although Brown has been shown to be a liar too, I think it is genuinely pathological. he just can't help himself. Anyway he's just useless and deluded.
You've missed the big story. It's that GPs' status as 'professionals' is now so shriveled that they feel they have to be anonymous when making these sort of observations.
The cancer referral stuff is just deckchair rearrangement. The real tradgedy is that a cynical government successfully used a vast dollop of taxpayers' money to manipulate a formerly respected profession into a bunch of whipped curs. GPs have abandoned their patients in the pursuit of a game-show points system, and rightly despise both themselves and their employers for the results.
In the post below, when someone critiques your response to the ad, you say "read the next post dick" (sic). Yet this post does not contradict the claim made in the ad. It basically just says that it doesn't matter or it isn't relevant or an incorrect policy. That's different.
Will, I think you'll find that many GPs were quite happy to accept the £100K+ salaries they now enjoy as the heavy burden of accepting government diktat!
Anyway, in the NHS system, GPs have always played the role of initial rationer, determining who gets what access - a system that has never really worked well, since, foolishly, many GPs have tried to put their patient's welfare above that of the penny-watching accountants in the hospitals.
Rationing is self-evidently going to have to get tighter, especially with novel treatments and we are going to see far more pressure on the NICE system from patient anger. I seriously doubt that Tory ministers will be any better at facing this down than were Labour ones, so the current reality, that novel expensive treatments will force out basic care, will continue and flourish.
The drug companies will be rubbing their hands in anticipation!
This is largely a queuing theory issue in my opinion
The flow of patients is likely to be fairly constant except in A&E at weekends; GP surgeries in the winter; perhaps after a health scare story.
The following is a considerable simplification of QT.
With a constant flow of patients then all can be seen in reasonable time if the medical staff are occupied for only 80% of their time. If they are 100% occupied , as I am sure they are, then queues develop. To see most patients immediately then the “occupied” status figure falls to 50% - that is 100% overstaffed. Appointments are intended to even out the queue over time to avoid that.
Many years ago the Post Office did queuing theory based research. Before that different counters may have been devoted to a specific function – say car tax – or else each counter attracted its own queue. Banks were the same. Should you be in a queue where people in front were paying in bags of cash, or had a difficult transaction then you could be seriously held up whilst other queues were being quickly processed.
I think the NHS targets are perhaps a variation of this. Patient choice also has a significant effect. We have all sat in a GP surgery where most patients opt for a particularly favoured GP. The people waiting for him/her wait rather longer than the rest.
The Post Office, and then the banks, now the railway ticket offices, solved the issue by creating a single queue with several service points serving that queue (cashier number 4) , although big queues will still develop at lunchtimes when many more customers appear.
Yes I know that banks and post offices are not comparable to the NHS with its many specialisms but I do think that the whole issue has been handled in a cack handed way to satisfy political dogma.Medics look not to have been consulted in any meaningful way.
rather than 'but i don't have time' the cry should be 'why after all the billions poured into the nhs over the last decade are 5 year survival rates so poor compared to other comparable developed countries'?
But why oh why oh why oh why has DC not been hammering on stuff like this. He just smiles and takes it on the chin. REBUTTALS.
Hopefully he will realise this before Thursday.
Just heard from a friend, who has a sister who has just died. Cause of death on the death certificate was smoking. Odd because she never smoked in her life.
Are the medical profession under orders to fudge the figures I wonder?
Took a lot of complaining to have this removed from the certificate.
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