I’ve been thinking a lot about non-Covid harm over the last year. It became obvious during the first week of the March lockdown that we were going to have an issue. Total Triage (TT) and virtual consultations were a huge change in how we provided care. It wasn’t unwelcomed in my practice; we had been considering moving to a TT model for a while but simply hadn’t been brave enough to make the change. It felt very different though, it was much more transactional than our traditional face-to-face model.
Whilst it worked, it grated a bit. It felt like something was missing. As GPs we are trained to value the complexity and deep potential of face to face consultations. Roger Neighbour’s Inner Consultation was engrained in me as a trainee GP, and it’s worth a browse even if you are not a clinician. Video consultations arrived soon after and seemed to be the solution. I liked the medium and was commissioned to write a series of articles for Pulse Magazine on effective remote consulting. I remain convinced that video is the essential tool to bridge the gap between a physical consultation and a telephone (or text) based one. It’s underused though. I have seen data suggesting (and I’ve no reason to doubt) that the rapid uptake of video by GPs at the start of the pandemic has fallen away. Video can be inefficient and takes effort especially when engaging with hard-to-reach groups. I have the same issue FaceTiming my Dad. It’s fantastic when it works, and I do it a lot, but telephone is quicker and more reliable for a quick chat. Primary care is a pressured environment, so the speed of the telephone is tempting.
As well as having a different mode of consulting we also have a different gateway to care. As I mentioned above, TT is now the default mode of access, whether practices are offering that through a reception model, e-portal, or electronic consultation system. It’s wonderful and efficient, but also rather blunt. It’s less easy to make an appointment for a bad knee, and then slip in “while I’m here I’ve had this bleeding…” The worrying symptoms often come after the less significant one.
Neither TT or remote consulting are wholly to blame, and their disadvantages could be designed out. Adding a default question to a TT submission form of “Is there anything else you’d like to ask the doctor, perhaps something that has been worrying you, or been on your mind” would be interesting. So too would changing the default channel of remote consulting to video from telephone. These two steps would go a long way to making us much more accessible. Potentially harder to address are the psychological barriers to seeking healthcare. During the “quiet” phases of the pandemic there has been much encouragement for routine healthcare to continue. I’m not sure though whether that has truly given permission to “bother the busy doctors”, nor whether it overcomes the fear of nosocomial infection. There are also issues around access to screening and secondary care diagnostics themselves.
The end point of this is that we are left with a huge amount of hidden disease. Conditions that would have presented themselves in normal times, but are still being self-managed, or ignored. I wonder about our chronic disease management. Quality and Outcome Framework (QOF) reviews have slowed or stalled. Medication reviews have suffered too. The inevitable progression of frailty is not being detected until a frailty crisis occurs. There is going to be a lot of catching up to do.
Cancer is a real area of concern. We’ve done so well in recent times with the move to a clear and unequivocal framework for the management of suspected cancer though the NICE “Two-week rule” pathways. The pathways are designed to be sensitive, so that your risk of actually having cancer after being referred is relatively small – around 3%. The success of the pathways is the ability to refer a relatively large volume of patients efficiently and rapidly to detect disease at an early and very treatable stage. The problem is the volume of patients being referred through the pathways has fallen off a cliff in the last year.
Macmillan published a summary of the issues in October which is worth a read. Their analysis is that cancer referrals fell by 28% in the first phase of the pandemic. There was some improvement by last summer, but with levels still around 10% lower than usual. We are now deep into wave 2 of the pandemic and I suspect analysis later this year will show a further worrying gap.
So, what can we do about this?
Awareness amongst clinicians and the public alike must be of prime importance. Guidance such as from Cancer Research has been published urging clinicians to be vigilant and addressing some specific issues.
My thoughts are:
- We need to make the issue personal. The Macmillan report suggests a possible 42,000 “missing” cancers in England. Proportionately that means my (large) practice could have twelve missed cancer diagnoses. As a clinician I really wanted to know what cases, or who has been missed. These are not just statistics; these are faces to me. Small numbers at a local level are easy to grasp.
- Second, we need to raise awareness of specific symptoms that may have been hidden by the pandemic. The classic one is the persistent cough and the risk of lung cancer. For most of the last year we’ve been telling patients with a cough to stay away and get a Covid test. We used to do the opposite! The British Thoracic Society has published helpful guidance here but I’m not sure how well known it is. A protocol of a negative PCR test followed by a Chest X-ray sounds a sensible place to start.
- Thirdly as highlighted in the Cancer Research guidance above, safety netting is key and having a low threshold for revaluating persistent symptoms.
- Fourthly we need to make our patient pathways easier and quicker to navigate. Adding a webpage with “worried about symptoms of cancer?” to the practice website could offer “permission to bother”. This could link to a fast track route to triage.
- Lastly we could consider direct referral for cancer diagnostics – that’s for patients not doctors! The rules are pretty clear thanks to the NICE guidelines. If a woman finds a breast lump and presents to me, she needs investigation. Much as I’d like to think I offer a skilled and experienced medical opinion, we generally don’t examine and reassure women presenting with discrete breast lumps anymore – they are referred. Making the GP the gateway simply adds a barrier to access and potential delay. Similarly, our patient with a new persistent cough almost certainly needs a chest x-ray as a minimum regardless of any clinical examination findings. Can we design a direct access pathway? BUPA launched an offering in 2017. I’d be interested in seeing their business case as I suspect in addition to offering access to their patients the service is cost effective. Sadly, earlier cancer diagnosis is cheaper than late. I would expect that an NHS Direct Access Cancer Pathway would be well-integrated into primary care pathways, simply helping to remove the barriers.
I hope we are nearing the peak of our second wave, and that things will start to improve. I welcome the frenetic activity of the vaccination programme, but I fear this will distract us further from addressing non-COVID harm, before the pressures on the health system ease to the extent that we can really get back towards normal. In the meantime, we should remain vigilant about the need to catch up with cancer.
Jonathan Inglesfield
January 2021
The Deer Doctor 