1. Camden Two Week Wait Referrals Feedback
Camden GP Education Event

2. Survey questions
Looking back at the last 20 referrals you received from GPs on the 2- Week Wait/ Target Pathway, were they appropriate? (e.g. 18/20 were appropriate, 2/20 were inappropriate)
If referrals were inappropriate, please indicate the reasons why below for each case.
Were there tests that a GP could have done prior to referral (Please indicate which tests)?
Were there treatments that a GP could have tried prior to referral (Please give examples of types of treatment)?
Should the referral have gone to another speciality (Please indicate which speciality)?
Should the referral have been a non-urgent referral instead?

3. Survey questions
If the referral was appropriate, is there anything else that GPs could have done to make the speed to diagnosis faster e.g. specific tests or trials of treatment?
What was the main test you requested for most of your patients seen on a 2-Week Wait referral?
Are there any specific cases where something was done particularly well by the GP?

4. Multi-Disciplinary Centres (MDC)
15/21 were appropriate, 6 were inappropriate.
Case 1
Case 2
Case 3
Case 4
Case 5
Were there tests that a GP could have done prior to referral (Please indicate which tests)?
No, all bloods supplied No
OGD referral
Were there treatments that a GP could have tried prior to referral (Please give examples of types of treatment)?
Simple painkillers
Treat for IBS
No. Already given PPI
Should the referral have gone to another speciality (Please indicate which speciality)?
Yes, UGI 2ww pathway rather than MDC
Yes. Complex patient with gastric pacemaker. Probably more appropriate to get functional gut team at RFH to see urgently
Should the referral have been a non-urgent referral instead?
Probably. No details on abdo pain given. Inadequate details main issue (despite 9 page referral)
Definitely. Longstanding groin pain with USS from 2 years ago showing lipoma. No way this is a ‘cancer’
Yes. Extensively worked up at RFH. No suggestion of cancer. Barn door IBS
No, 2ww ref appropriate
No, urgency appropriate

5. Multi-Disciplinary Centres (MDC)
Case 6
Case 7
Case 8
Case 9
Case 10
Were there tests that a GP could have done prior to referral (Please indicate which tests)?
Yes.
Fbc/ferritin/TTG
No, very conscientious referral
They’ve done them, but at RFH so results available
No, all bloods done
TTG
Were there treatments that a GP could have tried prior to referral (Please give examples of types of treatment)? No
Should the referral have gone to another speciality (Please indicate which speciality)?
Should the referral have been a non-urgent referral instead?
Possibly. Submitted material does not match referral box ticked on MDC pathway
No, appropriate referral with weight loss
No, appropriate for MDC pathway

6. Multi-Disciplinary Centres (MDC)
Improvements that could be made to increase speed of diagnosis: Virtually all gastro referrals require FBC/ iron studies/ TTG and to quote them in the referral. Previous imaging is useful but easier for the hospital to arrange therefore not necessary. For MDC referrals, CA125 useful for abdo pain/weight loss.
Main tests requested: CT scanning, which obviously wont be available to GPs, but in terms of useful bloods see answer to previous question.
Good practice: Yes – plenty! What links them is a coherent referral (not just reproducing clinic notes) with a full range of bloods.

7. Upper GI 19/20 were appropriate, 1 inappropriate 2. Case 1
Were there tests that a GP could have done prior to referral (Please indicate which tests)? No
Were there treatments that a GP could have tried prior to referral (Please give examples of types of treatment)?
Diet
Should the referral have gone to another speciality (Please indicate which speciality)?
No, gastro appropriate
Should the referral have been a non-urgent referral instead?
yes,. No indication on the referral of any red flag symptoms

8. Upper GI
Improvements that could be made to increase speed of diagnosis: Two refs had no bloods, 2 further ones referred to attachments that weren't attached. One was referred for weight loss and then had no relevant history, just documented a psych consultation. In general bloods are the most important, none of the weight loss refs had coeliacs serology documented for instance
Main tests requested: OGD CT
Good practice: Some great refs which had a few lines of relevant history, a set of bloods and/or relevant imaging

9. Haematology
12/20 appropriate, 8 inappropriate – 2 have no clinical details. 2.
Case 1
Case 2
Case 3
Case 4
Case 5
Were there tests that a GP could have done prior to referral (Please indicate which tests)?
chest XR, heart examination, urine tests No
Yes.. infection screen. GP misunderstood the interpretation of a blood test result. If advice was sought first, the right speciality (general medicine) could have been chosen
USS abdomen
Was referred on recommendation on Gastro at UCLH for a borderline 11mm node. This could have been dealt with internally. Based on the history, this is very unlikely to be a cancer
Were there treatments that a GP could have tried prior to referral (Please give examples of types of treatment)?
Depends on diagnosis
N/A
Should the referral have gone to another speciality (Please indicate which speciality)?
May infectious disease
Yes
Should the referral have been a non-urgent referral instead?

10. Haematology Case 6 Case 7 Case 8
Were there tests that a GP could have done prior to referral (Please indicate which tests)?
USS scan . Patient gives a good history of infection. GP could have ordered scan and reassured
CXR, infection screen. Also no details on why referral was required
No information received with referral
Were there treatments that a GP could have tried prior to referral (Please give examples of types of treatment)? No
Should the referral have gone to another speciality (Please indicate which speciality)?
General clinic
Should the referral have been a non-urgent referral instead?
Yes

11. Haematology
Improvements that could be made to increase speed of diagnosis:
The main reason for referral was an abnormal blood result but the only one missing was that abnormal one! Some symptoms are particularly difficult... like weight loss or sweats..
Many reasons, often NOT haematological in nature. (They need further investigation by specialists but not sure haematology is the best place).
Some referrals are right to come to haematology.. like Unexplained splenomegaly BUT in the absence of any other signs, does not need to be a 2ww. Treatment in terms of haematology 2ww is not applicable. GPs could have used Advice and Guidance instead (but we don't really offer this).

12. Haematology
Improvements that could be made to increase speed of diagnosis:
We can then help them judge appropriateness of referral and also urgency. But we don't offer this and also GPs and patients would prefer if they had an appointment in hand... Advice Guidance doesn't offer this. That pathway might need rethinking.
We have too many patients that are referred with sweats with no other reason. Arguable whether this should come here by default as they also go to Derm, and ID. If GPs have direct access to US guided Lymph Node biopsies, in theory, the diagnosis of lymphoma can be refuted or diagnosed faster. But this is tricky.
It would MASSIVELY help if we can see GP records and investigations. Use of CIDR and MIG via eCL will be transformative for our practice.

13. Haematology
Main tests requested: USS guided LN Bx Blood tests PET- CT and CT Scans Bone Marrows
Good practice: Yes.. when the GP has completely the myeloma screen. But the most important by far is taking the time to dictate or type the reason for referral rather than just tick some boxes. Impossible to then assess the referral.

14. Lower GI 16/20 were appropriate, 4/20 were inappropriate. 2. Case 1
Were there tests that a GP could have done prior to referral (Please indicate which tests)? No
Yes – Hb/ferritin
Were there treatments that a GP could have tried prior to referral (Please give examples of types of treatment)?
Should the referral have gone to another speciality (Please indicate which speciality)?
Yes – possibly haematology as anaemic but not iron deficient
Yes – gastroenterology. 34 with GI symptoms does not make a 2ww colorectal ref
Should the referral have been a non-urgent referral instead?
Yes
Yes, probably

15. Lower GI
Main tests requested: No – just Hb and iron studies on every patient please
Main tests requested: Colonoscopy
Good practice: The vast majority were sensible well-judged referrals with bloods done