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Implementing guidelines for suspected cancer

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Author Victoria Hoban, BA, is freelance journalist.

When nurses at a walk-in centre in Manchester identified a gap in the service for people with suspected cancers, they adapted NICE guidance to address this. Victoria Hoban reports

Nurse-led walk-in centres across the UK have played a crucial role in appropriately streaming patients to primary care, alleviating the pressure on the A&E four-hour wait target and developing the skills of nurses. As new services, they can also highlight gaps in patient care that may have been overlooked.

This was the case with the Primary Care Emergency Walk-in Centre in central Manchester. Soon after the nurse-led service opened in February 2005, anecdotal evidence revealed that patients were presenting with symptoms of suspected cancer. This was then substantiated by a three-month audit.

At the time, there were no systems to refer patients on to the urgent suspected cancer pathway. Instead, decisions on patient management depended on individual clinicians. The team has now implemented a system based on the NICE referral guidelines for suspected cancer (NICE, 2005), which is successfully ensuring patients at risk no longer slip through the net, including those not registered with a GP.

Identifying the problem
Soon after the walk-in centre opened, it became apparent to the primary care emergency service nurses there that patients were presenting with symptoms of suspected cancer but the processes for referring such patients were inconsistent.
Patients with suspected cancer were either referred back to their GP or to A&E. The former was undesirable as some patients at the centre were unregistered or, if they were registered, had attended the centre on the basis of patient choice and may not have wished to see their GP.

Directing the patient to A&E was often inappropriate as patients were often not acutely ill and did not need urgent investigation. Referral could also have adversely affected the four-hour wait target in A&E.

‘Patients were being admitted for diagnostic tests, which is not always appropriate,’ says Rachael Walsh (pictured), lead nurse assessor at the Primary Care Walk-in Centre. ‘If we referred unregistered patients to a GP, it might take up to a month for an appointment. With suspected cancer, time is precious.

‘There is an assumption that every patient has a GP. Unregistered patients were therefore extremely vulnerable.’

The nurses decided to consider using the NICE (2005) referral guidelines for suspected cancer.

‘We felt NICE guidance was best practice and we wanted equal referral pathway for all patients,’ explains Ms Walsh. However, the existing guidance for suspected cancer did not include specific advice for walk-in centres, so she and her team had to consider adapting it.

‘The guidance says that the referral form has to be done by the patient’s own GP or dentist. But this isn’t always possible, and it isn’t always appropriate to refer to the consultant.’

Ms Walsh and her team took their findings to the cancer lead in the PCT, who liaised with other UK cancer leads and with the Department of Health policy team for referral guidance and liaison. It was discovered that, although the cancer referral process in walk-in centres had been identified as a problem, it had not been addressed.

A mini audit was conducted between March and June 2007 to assess how many patients fit this category and to understand something about presenting symptoms. During this period, 13 patients presented with symptoms of suspected cancer – hardly an insignificant number.

The team contacted the local cancer collaborative and cancer network, which accepted the project as a test site. They also set up a project group of stakeholders including booking managers at the referral booking and management centre (RBMC) and the local medical council.

The project group decided to implement the NICE (2005) referral guidelines for suspected cancer at the walk-in centre in the same format as for general practice and dentistry.

To achieve this, thorough preparation was needed. It was necessary to:
- Explore the feasibility of implementing the referral guidance at the walk-in centre;
- Implement a standardised process of referral for all patients, regardless of GP registration status; and
- Implement an immediate GP registration process for unregistered patients.

Intense work was undertaken with Patient Data (which registers patients with a GP) at the strategic health authority to establish a system of immediate GP registration. This was to ensure ongoing care is provided following a serious diagnosis.

They also persuaded the RBMC to accept patients who were not registered with a GP.
‘They are now happy for nurses from the emergency centre to refer patients which is a big achievement,’ says Ms Walsh.

‘This has resulted in us building up stronger networks with primary care services and there is better continuity of care.

‘It is also a way of empowering nurse clinicians at the centre while also reducing the four-hour waits in A&E, as we don’t have to wait for a clinician.’

Following six months of detailed project work, the NICE referral guidance for suspected cancers was implemented at the walk-in centre on 20 August 2007.

This entailed developing detailed protocols in the form of flowcharts that outline the process for different scenarios, such as whether patients are registered with a GP or not
and whether they live in or outside of the area. Information for new patients explains
the process of referral and follow-up, and is given to each patient together with a verbal explanation.

In liaison with the local cancer collaborative and cancer network, a template has been devised to capture qualitative and quantitative data on all patients referred on the new pathways. This will constitute the testing phase of the project and run until spring 2008.

Quantitative data includes: age, gender, ethnic origin, GP registration status, suspected tumour site, outcomes of conversations with the patient’s GP prior to referral, success or otherwise of the administrative processes, and the final outcome of the referral.

Qualitative data includes information on the patient and GP’s perspective of the referral process.

‘We have learnt that it is possible to safely implement the NICE referral guidance for suspected cancers in a walk-in centre, but there must be detailed engagement with all stakeholders for this to be a success,’ says Ms Walsh.

She notes that: ‘It can be a time-consuming process but rewarding in that the patient experience is improved as a result of direct referral.’

There is a need to establish why some patients are not registered with a GP and whether systems that rely on this are appropriate for the new NHS, which offers patient choice at the front end of care.

NICE (2005) Referral Guidelines for Suspected Cancer CG27.


Box 1. Recommendations for primary care staff

- You should be able to identify typical presenting features of cancers and be alert to the possibility of cancer when confronted by unusual symptom patterns or patients failing to recover as expected;
- Systematically review the patient’s history and examination, and refer urgently if cancer is a possibility;
-Discuss with a specialist if there is uncertainty about the interpretation of symptoms and signs, and about whether a referral is needed;
- Recognise parents are usually the best observers of their children and listen carefully to their concerns. Be willing to reassess the initial diagnosis or to seek a second opinion from a colleague if a child fails to recover as expected;
- Investigations should not be allowed to delay referral and should be undertaken urgently to avoid delay. If investigations are not readily available locally, an urgent specialist referral should be made;
- When referring a patient with suspected cancer to a specialist service, assess the patient’s need for continuing support. Provide information to the patients, family and/or carers as appropriate;
- Keep up to date with the skills necessary for early diagnosis and referral and for communicating the possibility of cancer to the patient.



Box 2. Key points for implementing this guideline

- Make sure you form a project group that involves all stakeholders including the local medical council and local cancer collaborative;
- Do not rush the process. Have a thorough preparation period during which time all potential barriers can be addressed;
- Liaise early on with equivalent centres around the UK to uncover any existing solutions or ongoing projects;
- Make sure you follow up patients to examine whether the process is working or if new ways of working are required;
- Immediate referral for unregistered patients is vital to implementing this guidance successfully.


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