1. Recognition and Referral of Suspected cancer NICE NG12 – 2Week Wait
Dr Katie Elliott
Assistant Clinical Lead
CRUK Strategic GP Northern Cancer Alliance
Macmillan GP NE&C Learning Disability Network

2. 2 Week Wait
NHS measures trusts against the Cancer Waiting times standards. One of the measures is:
a maximum two-week wait to see a specialist for all patients referred with suspected cancer symptoms

3. 10 Acute Trusts
>400 GPs
12 CCGs
12 tumour groups

4. NEW GUIDANCE - Recognition and referral for suspected cancer NICE NG12
Identify more cancer at an earlier stage
Symptoms based
Early referral/ direct to test in primary care
BLOOD TESTS/ CXR/ CT/ MRI
Minimum Positive Predictive Value 3%
Implications for referral pathways
Impact on diagnostic services
Impact on patients and systems

5. Investigations or referral for suspected cancer
Recognition and referral for suspected cancer - NICE NG12
Symptoms in children and young people
Investigations or referral for suspected cancer
Cancer site
Symptoms
Investigation
results
Safety netting
Information and support for people with suspected cancer and their families

6. Primary Care – Urgent tests
Bloods
FBC within 48hrs
CA125
PSA
U+E, Coag screen/calcium/Plasma electrophoresis/ESR
CXR 48hrs
Plain x ray 48hrs
USS 2ww
CT 2ww
MRI 2ww
Understand the importance of timely access to blood tests in primary care
Unexplained bruising, lymphadenopathy, pallor
women > 50 with sx of Ovarian cancer
PSA -can be done same day as PR examination
U+E - not specified in NICE but essential for direct to test for CT / Colonoscopy/ Lung/
CXR – be aware of your local escalation pathway - Chris to discuss more later
USS/ CT/ MRI – 2ww drop down option available in ICE - use it but be clear about the criteria and U+E required

7. Secondary care - urgent clinics
One stop clinics
Breast
Neck lump
Colposcopy
Gynaecology
Hospital needs:
Correct information on the referral form. Blood test results
Communication needs and reasonable adjustments
Straight to test
Upper GI- CT/ Endoscopy
Lower GI- CT/ Endoscopy
Lung- CT/ Bronchoscopy
Patient needs

8. Opportunity to develop standard, region wide referral forms
Benefits
One form for all practices to all trusts for each tumour group
Up to date criteria. Only one form to change if guidance changes
Link with GP IT system
Facilitate straight to test
Move away from hand written forms/ fax
Concentrate on clinical narrative and criteria for referral
Reduce risk of delay due to wrong form/ wrong information

9. Development Work with the Expert Groups Cancer managers
Cancer Nurse Specialists
Cancer in the community group – locality leads
Improving Referral Forms Through Collaborative Working – Gateshead Team
Dr Forbes
NECS
Detailed review of guidance
Review of existing referral forms

10. Success? YES…. Single form for each speciality agreed Standard lay out
Information merged from GP clinical system
All GPs have access
Mostly working ok
BUT…….
Difficult to use in hospital
Visibility of information
Relevance of information
Incomplete information- performance status
Still some work to do

11. Key learning from the review:
Generic changes to forms improve lay out and function
One stop clinics and straight to test need accurate information.
Some triaged within 24 hours, blood tests must be taken ON day or BEFORE the referral is sent
Incomplete information - can cause delay
Clinical information and performance status completed by referring clinician
Help primary care understand the importance of the information on the referral form
Survey went out to all practices, trusts, booking teams – 371 responses. 80% primary care.
Mostly working in primary care.
Very lengthy forms and variable quality and completeness in secondary care.
Clear issue about forms being completed by non clinicians - performance status and reason for referral often incomplete
These forms are now one o the key tools to being able to streamline services getting patients straight to test before being seen in clinic or getting tests done in ‘one stop’ clinics. Incomplete forms may delay the journey for your patient.
There are 2 main areas for completion – reason for referral and performance status where requested. Additional boxes about some drugs also required in EMIS.

12. Information and Support for patients and their families
Tell people they are being referred/ investigated for suspected cancer.
Explain what to expect from the referral/ investigation.
Make reasonable adjustments - consider written information.
Most people referred urgently will not have cancer.
Secondary care team still concerned that people are coming in unclear about why they have been referred
Use the word cancer
Easy read leaflet soon to be available - has had input from LD groups and Alzheimer's society.

13. NE & C Learning Disability Network + Northern Cancer Alliance
Julie Tucker
Easy read version of the National standard patient information leaflet
Gateshead People
Alzheimer's society

15. Easy Read Patient Information
The easy read PIL for each trust is now available on the Northern Cancer Alliance website.  
Please promote this to people and GP practices in your area and support us in making services more accessible.

16. What is safety netting? Management of clinical risk
I am not worried today but if this happens…
When should I come back to see the doctor?
Management of organisational risk
How do I know this process works?
What is the back up plan?

17. Top Tips to take away…
What are the top three tips you will take away from today?
How will you use them within your practice?
Who will you share this learning with in your practice?
CRUK Safety netting booklet
Macmillan Top Ten Tips
Safety netting read codes

18. Resources Northern Cancer Alliance Website
NICE
CRUK health professionals page -
Macmillan – Ten top tips – safety netting, Easy read materials, rapid referral advice
RCGP e-learning free to members - early cancer diagnosis module
GP Update/ MB Medical - cancer update courses