gp significant event audit report north of england cancer network december 2012

GP Significant Event Audit Report

North of England Cancer Network

December 2012

Title North of England Cancer SEA Report

Reference SEA _GP Audit_NECN

Version V03 Final

Date 08.01.2013

Author Parry Lothian Consultancy

Change History

5/9/12 V01 Draft for Clients

12/09/2012 V02 Final Draft

08/01/13 V03 Final

North of England Cancer Network SEA Report 2

ContentsContents

1. Introduction2. Context and Background3. Methodology

• The Approach• Practice Participation• The Participating Practices• Practice Locations and Population

4. The Audit Process5. Analysis

• Overview• Audits by Cancer Site• Age Profile• Attendances• Referrals• 2WW• Avoidable Delays in the Patient Journey• Lessons Learned• Changes Made• Perceptions of the effectiveness of the audit

6. Learning, Messages and Reflections• All Cancer Sites• ‘Top 4’ Cancer Sites

7. Recommendations8. Acknowledgements


IntroductionIntroduction


IntroductionIntroduction

This report describes the process and outcomes from the North of England Cancer Networks’ (NECN) GP Practice Significant Event Audits. This is another element of work

progressed under the umbrella of National Awareness and Early Diagnosis Initiative (NAEDI).

The report highlights the specific findings, the issues raised and the local actions taken to improve specific elements of the care pathway both at practice level and within interfaces

with secondary care.

It makes recommendations on the transference of learning, local communication and further work that will require action.

Initial presentation in Primary Care

Reducing the time delay and waste in the patient journey to support earlier cancer diagnosis

Diagnosis

Lung Cancer Significant Event Audit and The National GP Audit

GP Practice Significant Event Audits – the subject of this report

Cancer in Primary Care - the initial NAEDI work


Context and BackgroundContext and Background


Context and BackgroundContext and Background

As part of the NAEDI to promote timely diagnosis of cancer, a national significant event audit of cancer diagnosis in primary care was commissioned and reported in 2009. This audit in the north east of England was carried out by a collaboration between Durham, Glasgow and Dundee Universities. This primary care audit study was specifically to gain insight into the events that surround the diagnostic process for two groups in cancer (lung cancer and cancer affecting teenagers and young adults). The full report can be found on www.cancernorth.nhs.uk

From the initial study above a further project was initiated by NHS County Durham and Darlington and extended to NHS South of Tyne and Wear. This project was to work more closely with primary care to identify, analyse and find solutions to issues that prevented quick diagnosis as identified in the significant event audit (SEA). As NHS North East were already well advanced in their application of the Virginia Mason Production System the proposal suggested that this vehicle was used to carry out this ‘new ‘work building on from and using the initial findings for lung cancer.Durham University, School of Medicine and Health has evaluated the Virginia Mason Production System as it is applied to this primary care work.Both reports can be found on www.cancernorth.nhs.uk


Building on the previous NAEDI work the Network participated in the National GP Audit developed by the Royal College of General Practitioners and the National Cancer Action Team. The overall aim was to build on current good practice and inform service improvements thereby ensuring that individuals with symptoms suspicious of cancer are referred appropriately and early. 22 practices participated in the first round of this audit.The report can be found on www.cancernorth.nhs.uk

Cancer in Primary Care - the initial

NAEDI work

The second project on NAEDI

The third project on NAEDI

General Practice Profiles were developed by National Cancer Intelligence Network (NCIN), National Cancer Action Team (NCAT) and Association of Public Health Observatories (APHO) and were first released in 2010. The profiles provide practices with comparative information for benchmarking and reviewing variation. GP Leads in NECN identified practices in their respective localities which varied from the PCT average on certain key indicators. GP Leads visited these practices to help them reflect on their data and invited them to participate in an audit of cancer diagnoses over a 2 year period. 26 practices participated in this audit.

The fourth project on NAEDI

Context and Background continuedContext and Background continued

The fifth project on NAEDI – the subject of

this report

The North of England Cancer Network (NECN) are now building upon the previous NAEDI work by encouraging constituent GP practices to carry out regular significant event audits on all cancers. This work has been developed and facilitated by the NECN GP Cancer Leads.

The aim of these audits is:

•To identify any avoidable delays in patient pathways•To use the findings to plan interventions to improve early diagnosis within the practice and across the North of England Cancer Network•To develop good clinical practice and raise awareness of early diagnosis•To identify lessons learnt and changes made that can be transferred to other practices

Overall the aim is to build on current good practice and inform service improvements thereby ensuring that individuals with symptoms suspicious of cancer are referred appropriately and early.


MethodologyMethodology


Phase 2 – Planning and Recruiting

Phase 3 – Date Collection and Cleansing

Phase 4 – Data Analysis and Reporting

Phase 1- Project Initiation

A SEA Audit by the North of England Cancer Network agreed by the Cancer in the Community Group.

Aims and objectives of the SEA audit agreed.

Audit parameters agreed.

Timelines and GP practice responsibilities agreed.

Scope of practice participants agreed.

Remuneration for practices agreed.

Project Group and Activity Plan developed.

Briefing Pack and Practice agreement developed.

Each participating GP/practice was given from December 2010 to January 2012 to complete and submit the audits.

The records were validated and the data cleansed and amendments agreed with each participating GP where appropriate.

The data was analysed and the main findings agreed with the Cancer in the Community Group

The report developed and signed off in September 2012

• Audit parameters and timelines.

• Project Plan

• Briefing notes for participating practices and GPs

• Completed, Validated Audits.

• Data analysis

• Final Report

Methodology – The ApproachMethodology – The Approach


Methodology – Practice ParticipationMethodology – Practice Participation


Methodology – The Participating PracticesMethodology – The Participating Practices

Participating Practices

Dr Cloak and Partners Sunderland

Springwell Medical Group,Sunderland

Auckland Medical Group,Dales

Brandon Lane Surgery,Durham and Chester le Street

Coquet Medical Group, MorpethNorthumberland

Millfield Medical Group,Sunderland

Lane End Surgery,North Tyneside

Harbottle SurgeryNorthumberland

Cockfield Surgery,Dales

Victoria Road Surgery,Dales

Hinnings Road,North Cumbria

Tennant Street Practice,North Tees

North House Surgery,Dales

Burn Brae,Northumberland

Peaseway Medical Centre,Sedgefield

Station View Health Centre,Dales

Murton SurgeryMurton, Easington

Denmark St Surgery,Darlington

Middle Chare Medical Group,Durham and Chester le Street

Spennymoor Health Centre,Sedgefield

Adrian Clark House and McKenzie House,Durham and Chester le Street

Brunswick House Medical GroupCarlisleCumbria

Jubilee Medical Group,Sedgefield

Oakfields Health Centre,Derwentside

Stanwix Medical Practice,North Cumbria

Queens Road Surgery,Derwentside

Falcon Medical Group,Newcastle upon Tyne

Seascale Health Centre,North Cumbria

Shildon Health Centre,Sedgefield

Greystoke Surgery,Northumberland

Haltwhisle Medical Group,Northumberland

St Anthony’s Health Centre,Newcastle upon Tyne

The Gateway Practice,Newcastle upon Tyne

The Surgery, Bellingham,Northumberland

Lowther Medical Centre,North Cumbria


Methodology – The Participating PracticesMethodology – The Participating Practices

Participating Practices

The Surgery,Newcastle upon Tyne

West Road Medical Group, Newcastle upon Tyne

3, Eden Terrace,Sunderland

10 Bewick Road,Gateshead

Deerness Park,Sunderland

Walker Medical Group,Newcastle upon Tyne

Fell Cottage Surgery,Gateshead

Fulwell Medical Centre, Sunderland

Herrington Medical Centre, Sunderland

78 Imeary Street,South Tyneside

Maritime Surgery,Sunderland

Marsden Road, South Tyneside

Rickleton Medical Centre,Sunderland

Second Street,Gateshead

Silksworth Health Centre,Sunderland

Dr Obanna, Sunderland

Victoria Medical Practice,Hartlepool

St Albans Medical Group,Gateshead

Whickham Health Centre, Gateshead

Martonside Medical Centre,Middlesbrough


This total number of 55 practices is a significant increase from the total of 22 practices who participated in the last NECN audit – The National GP SEA Audit.

The National Cancer SEA audit template was used for this project which facilitated participation by GPs as these can also be used towards individual personal appraisal portfolios – thus making it part of a GP’s ‘day job’.

It is also reasonable to assume that the increase in participation is due to the increase numbers of GP Cancer Leads working in NECN and the continuing work of the Network to engage with primary care and the new Clinical Commissioning Groups.

Methodology – Practice Locations and PopulationMethodology – Practice Locations and Population

Dotted Eyes © Crown copyright and/or database right 2008. All rights reserved. Licence number 100019918

55 Practices from across the NECN participated in this audit

Commissioning Cluster Participating Practice

Cumbria 5

Co. Durham and Darlington 16

North of Tyne 13

South of Tyne 18

Tees 3

Total NECN Population = > 3 million


The Audit ProcessThe Audit Process

North of England Cancer Network SEA Report15

Stage 2 – Defining the Data Set for Analysis

Stage 3 – Agreeing the Focus and Content of the Report

Stage 4 - Report development and sign off

Stage 1- Template completion and Submission

The Audit ProcessThe Audit Process

Qualitative analysis focuses on generic key learning , changes and messages extract from the very specific narratives of the completed audits.

In order to report across these narratives, specific to each completed audit, a data set was defined. This data set was used to restructure the narrative into a format more conducive to quantitative analysis.

Two meetings were held with the NECN to agree the focus and content of the report.

The first meeting agreed the data set and definitions. It also agreed the analysis and the focus of the report from the initial findings

The second meeting presented a draft report to the ‘Cancer in the Community Group’ to agree final content and format

Further development of the report was undertaken and submitted to the Cancer in the Community Group and finalised in October 2012.


This project used the national Cancer SEA Template, jointly developed by the RCGP and the National Patient Safety Agency. The template allows for structured narrative analysis by asking five key questions:•What happened?•Why did happen?•What has been learnt?•What has been changed?•What was the effectiveness of the audit?Audit parameters were:• Patients seen in the

previous 12 months • The GP completing the

audit was required to be personally involved with the case

• Cases diagnosed through screening were excluded

Timelines:December 2011 to January 2012

AnalysisAnalysis


Analysis – OverviewAnalysis – Overview

These Significant Event Audits have been designed as a quality improvement tool and are already widely used in general practice. They facilitate GP engagement and help bring together the practice team for reflective discussion around clinical practice.

By far the most important learning has occurred at Practice level. However, the challenge for this report is to extract key learning and subsequent changes, occurring a practice level, that may offer beneficial messages across the Network and encourage future and increased participation in the National Cancer Action Teams’ audit programme. Comparative analysis is not the focus of this report.

Quantitative metrics have been provided to offer the reader a sense of scope and range of the submitted audits and shown in a series of graphical presentations.

Learning, messages and reflections have been extracted from the completed audits and presented in a table format.


Analysis – OverviewAnalysis – Overview

The ‘free text’ format of the audit template provided an excellent vehicle for discussion and reflection at local practice level.

The ‘free text’ format, however, presented a challenge in the extraction of global issues and themes.

Where possible ‘free text’ from the audits was structured and defined into a dataset for analysis leaving a certain degree of interpretation in the hands of the authors of this report


Analysis – Audits by Cancer SiteAnalysis – Audits by Cancer Site


Analysis – Age ProfileAnalysis – Age Profile


Analysis - AttendancesAnalysis - Attendances


The majority of patients in this audit attended 1 – 3 times before referral. The 2 patients with no recorded attendances were admitted or referred from another source. The ‘Uncertain’ category represents those records where it was difficult to determine the number of attendances from the information provided. The ‘Ongoing’ category represents those patients who were accessing secondary care prior to diagnosis. This accounts for the apparent discrepancies when viewing the ‘Top 4’ cancer site graphs below

Analysis - AttendancesAnalysis - Attendances


Analysis - ReferralsAnalysis - Referrals


Of the 162 records 85 were identified as having been referred under the 2WW rule.

4 records provided insufficient detail to determine referral (uncertain)

Of the 73 remaining records reflective comments recorded within the completed audit identified:

•10 should have been 2WW referral•1 was a cancer without guidance on referral• 3 did not match referral criteria•6 acknowledged lessons learned using referral guidance


Analysis – 2WWAnalysis – 2WW

Of the 53 records that did not use the 2WW referral process some key reasons, identified in the audit commentary, may have been deciding factors .

These are presented as a % of the 53 records.

By far the most significant is the 38% of patients not presenting with symptoms suggestive of cancer and the 13% that acknowledged incomplete examination in primary care

The 26% of other reasons includes a combination of small numbers of reported factors such as:

•Patient influence•Apparent normal test results•Multiple consultations with different clinicians•Failure to consider previous history

23% of the audits reported no delay in diagnosis

Analysis – Avoidable Delays in the Patient JourneyAnalysis – Avoidable Delays in the Patient Journey

With most cancers, the earlier the diagnosis is made, the better the prognosis. One of the aims of the audit was to identify whether there were any possible delays in the patient journey.

A wide range of factors possibly affecting the patient journey were reported. 125 records stated possible delays – 223 reasons in total.

For the purposes of this report these have been categorised within the context of “A Health System” modelled below.

“Health System Model”

Communications Issues

Clinical Decisions and Actions

Patient Decisions and Actions Referral Processes None IdentifiedInvestigations and

Reporting

Factors relating to the clinical decisions and actions made in both primary and secondary care

Factors relating to poor or inappropriate communication that could have occurred at any stage within the patient journey

Factors relating to the failure, delay or reporting of investigations including relevance and timeliness

Factors relating to decisions and actions made by the patient

Factors relating to aspects of referral – such as timeliness, appropriateness and the referral protocols themselves

Individual records with no stated delays

91 reported

13 reported

33 reported

82 reported

4 reported

37Records



The above presents the “Health System Model” categories across all relevant records (125) and shows a summary of comments made regarding possible delays (223)



Analysis – Lessons LearnedAnalysis – Lessons Learned

Of the 162 records 113 of the audits identified ‘lessons learned’ In restructuring the information some audits identified multiple lessons - these have been categorised within the health system groupings resulting in a total of 146 lessons learned.


Take a broad view of findings – beware of ‘red herring’

symptoms

Recognition that specific clinical findings should mean

specific actions

Ensure appropriate safety netting and follow up

Appropriateness, use and restrictions of NICE

guidance

Secure a wide view of the patient’s health

Unpredictable events complicate matters

Opportunistic testing can be beneficial

Referral guidance does not always exist

Trust your instinct

A normal result does not automatically exclude underlying pathology

The importance of a full history

Continuity of care is essential 2

Unexplained weight loss must always be

investigated

Patients leave important symptoms until last in consultation

Telephone is fine but face to face is betterIt is important that the

patient understands their condition

VigilancePatient denial is

real and should be taken account of

Effective communication is

vital

Ensure you recognise training and education as a factor

Don’t assume follow up in

secondary care

17 5 6 8 5 12

22223

1 1 1 1 1 1

16 26 14 20


Analysis – Changes MadeAnalysis – Changes Made


Analysis – Perceptions of the Effectiveness of the AuditAnalysis – Perceptions of the Effectiveness of the Audit

Of the 162 audits 143 stated the audit had been effective. Of the 143 audits who stated the audit was effective they cited 165 reasons for effectiveness These reasons have been categorised above and graphed above.

North of England Cancer Network SEA Report

35

Learning, Messages and ReflectionsLearning, Messages and Reflections


Learning, Messages and Reflections – All Cancer SitesLearning, Messages and Reflections – All Cancer Sites

Clinical Decisions and Actions – A total of 78 lessons/messages were provided from across all cancer sites

It is important to take a broader view of examination findings in relation to symptoms - beware 'red herring' symptoms 26

The audits supported documentation of ‘what has been learned’ which forms the basis of the learning within this report. In addition, the audit asked ‘what has been changed?’ below represents changes which align to the lessons, but again, have been summarised and grouped to present a picture of how the practices addressed the outcome:

• Changes to clinical practice• Addressing administrative procedures• Reviewing how guidelines are used and

looking to standardise use• A direct revision to existing practice protocols

or the introduction of a new practice protocol• Specific action to improve the standard of

completed clinical documentation• In one case the introduction of additional

clinical testing / history to be completed during long term condition review clinics

Identification or recognition of very specific clinical actions required when very specific clinical circumstances occur e.g. Changing the threshold for chest x-ray in non resolving cough

20

The importance of considering the full history 14

Need for follow up procedures 6

Vigilance 5

Continuity of care is essential - from first presentation to end of life 2

Unexplained weight loss is a 'real' red flag and should always be investigated 2

In the case of rarely presenting patients take the opportunity to secure a wide view of their general health 1



Clinical Decisions and Actions continued

Lack of Education or Training 1

Trust your instinct 1



Communications Issues – 29 lessons identified

Ensure appropriate systems for safety netting and follow up 11The audits supported documentation of

‘what has been learned’ which forms the basis of the learning within this report. In addition, the audit asked ‘what has been changed?’ below represents changes which align to the lessons, but again, have been summarised and grouped to present a picture of how the practices addressed the outcome:

• Addressing administrative procedures• Addressing how primary care and

secondary care communicate to improve the process

• Changes to clinical practice• Looking at ways of improving patient

education and awareness• Specific action to improve the standard of

completed clinical documentation

Effective communication is vital and should never be underestimated 8

Patient denial or fear can be very real and should be recognised when communicating with the patient and deciding on actions 5

Be aware during consultations that patients may leave important symptoms / issues till the last moment 2

Telephone consultation can be useful but face to face is really important 2

Unpredictable events complicate matters 1



Investigations and Reporting – 13 lessons identified

A normal result does not automatically exclude underlying pathology 12The audits supported documentation of


• Addressing how primary care and secondary care communicate to improve the process

• Changes to clinical practice• A direct revision to existing practice

protocols or the introduction of a new practice protocol

• Addressing administrative procedures

Opportunistic testing can be beneficial1



Patient Decisions and Actions – 4 lessons identified

It is important that patients are aware of, and understand their condition 3 The audits supported documentation of ‘what has been learned’ which forms the basis of the learning within this report. In addition, the audit asked ‘what has been changed?’ below represents changes which align to the lessons, but again, have been summarised and grouped to present a picture of how the practices addressed the outcome:

•Addressing administrative procedures•Changes to clinical practice•Reviewing how guidelines are used and looking to standardise use

Patient denial or fear can be very real and should be recognised when communicating with the patient and deciding on actions

1



Referral Processes – 22 lessons identified

The use, appropriateness and restrictions of NICE guidance 16The audits supported documentation of


• Addressing administrative procedures• Changes to clinical practice• Reviewing how guidelines are used and

looking to standardise use• Looking at ways of improving patient

education and awareness• Specific action to improve the standard of

completed clinical documentation

Don't assume follow up in secondary care6


Learning, Messages and Reflections – Lung Cancer SiteLearning, Messages and Reflections – Lung Cancer Site

Extracts from the audit narratives relating to Lung Cancer Site

1Refers to child’s rare lung cancer It is important to auscultate the chest in any ill

and pyrexial child, even in the absence of overt respiratory symptoms

Also to be alert to follow up unusual complaints from parents (fremitus)

2The patient was high risk for ischaemic heart disease and initially the chest pain was labelled ‘cardiac’

Cardiac investigations were negative but they was high inflammatory markers which should have raised suspicion

Do not always assume that chest pain relates to cardiac problems

3

A smoker with significant risk of lung cancer presented with inexplicable back pain, lasting several weeks

There was absence of cough or shortness of breath and the clinical picture did not indicate lung cancer as a likely cause of the back pain. The GP ordered a chest x-ray but only attributed this action to experience rather than clinical indicators

On reflection all GP agreed to lower the threshold for diagnostic imaging, specifically chest x-ray

4

Abnormal weight loss was a classic “red flag” symptom . The reassurance provided by a normal diagnostic test could have caused a delay had the GP not also instigated a chest x-ray

The importance of having a low threshold for chest x-ray was discussed and it was agreed that this represented something of a change of mindset for many GPs who had been taught to be aware of exposing patients to too much lifetime radiation

The use of smoking “pack years” when considering smoking history was agreed as a good way of assessing smoking risk. All GPs were reminded how to access and use the computerized tool to calculate pack years




5

Presentation of a three week unexplained cough, in a known smoker. Patient also complained of changes to general well being and chest pain

Look at the patient, not the x-ray – look at the clinical picture in front of youContinuity of clinician is important in an evolving picture

Consider pain more thoroughly as an ‘alarm bell’.

There remains a dilemma as to whether to do a chest x-ray on every exacerbation of a known condition – the time to so a chest x-ray is when improvement is not a quick as expected.

Use our new waiting room TV screens to promote the benefits of giving up smoking, even for children’s clinic to show the dangers of STARTING smoking or being a parent and smoking

6

Distressed patient with mental health problems

Investigations in a distressed patient can be very difficult.Sometimes with a numbers of complaints and consultations it can be difficult to see the wood from the trees

In response the COPD annual review protocol has been changed to include questions on possible symptoms of lung cancer – abnormal weight loss, coughing up blood and increasing frequency of COPD exacerbations.The indications for chest x-ray requests are also to be highlighted within the practice team

7 Remember shoulder pain may represent lung/mediastinum pathology

8

Be sensitive to patients’ concerns and not stick as rigidly to investigation/referral guidelines

GP started a survey where each cancer diagnosis made was examined. The results serve as learning points informing the practice of any cancers missed and the accuracy and appropriateness of referrals




9Consider performing a chest x-ray in prolonged shoulder pains

10

Do not accept hospital treatment/diagnosis management plans if the most likely diagnosis has not been excluded

Be prepared to phone up, listen to patient concerns and to set up a dialogue with hospital colleagues

NICE/cancer 2WW referral is not the only means of getting an appropriate end result

11

Patient presented with a 3-4 week cough, with no other worrying symptoms or signs.On second consultation (7-8 weeks) still with persistent cough. Chest x-ray requested.

Chest x-ray showed likely chest infection, antibiotics prescribed and further chest x-ray in 4 weeks.

Second chest x-ray showed no change and the advice was to continue with antibiotics.

Patient developed haemoptysis and was referred under the 2WW

Anyone with a persistent or unexplained cough for more than 3 weeks (even at first presentation, with no other accompanying symptoms or signs) would merit a chest x-ray in the first instance. Always give patients adequate safe netting on when to return if symptoms (respiratory) persist

12

There was concern in retrospect that backache may have been a presenting feature of metastatic cancer missed in medical and physiotherapy assessments

Features of non mechanical back pain and red flags, together with ill health meaning an absence from work of over 6 weeks were felt to be indicative of under lying pathology

13

Where there are no obvious respiratory symptoms and a non specific presentation, a chest x-ray will be routinely included in investigations


Learning, Messages and Reflections – Colorectal Cancer SiteLearning, Messages and Reflections – Colorectal Cancer Site

Extracts from the audit narratives relating to Colorectal Cancer Site

1

Avoid complacency slipping into consultations - re-examination can be important

It is important not to accept clinical findings of previous examinations if history changes or symptoms are unresolved

NICE guidance will now be available on desk tops and not as paper copy – so easier to update and bring to mind

2Negative symptoms could have been documented clearer in the notes - such as weight loss and change in bowel habit

3

If pain is not settling as expected the diagnosis should be reviewed even when it is an apparent recurrence of previous problems

4

Any persistent rectal bleeding should be referred, even if NICE cancer guidance referral criteria is not met

Clinicians should trust their instinct about the need for investigation urgently, even when NICE two week rule criteria are not met

5Some false reassurance from an earlier ultra sound scan

Possibly some false reassurance from detecting H Pylori as a possible cause

It is important to get second opinion from colleagues if patients are returning repeatedly with unexplained symptoms

6

When patients are discharged from secondary care follow-up and you feel the outcome is unsatisfactory it is important to phone the hospital and speak to one of the team members

7 Other risk assessment tools are being considered e.g. Willie Hamilton’s .

This may mean more patients fall within a 2WW referral pathway


Learning, Messages and Reflections – Colorectal Cancer SiteLearning, Messages and Reflections – Colorectal Cancer Site

Extracts from the audit narratives relating to Colorectal Cancer Site

8

It is better to refer to an NHS site if there is a high chance of cancer as investigations carried out on a non NHS site will still require an onward referral from the GP to an NHS site

9Is it important to take a detailed family history in anybody presenting with rectal bleeding

10

Passing blood mixed with the motion at any age needs investigation and definitive diagnosis

Irritable Bowel Syndrome is not a firm diagnosis but one to be made when others have been excluded

11

It is our responsibility to ensure patient being referred under 2WW are getting timely investigation

The patient should know what to expect from a 2WW referral. They should be clear that they are expected to be seen within 2 weeks and that investigations should be completed within 31 days and be able to receive treatment within 62 days

All patients are to be given a 2WW leaflet with clear instructions when to call if there is an apparent delay.Be proactive to speak to the hospital and be persist with the request.If a timely response is not achieved, be prepared to go further. Practices should have a tracking system to follow the referral.

12

ESRs are carried out as part of a battery of tests when diagnoses are uncertain. They can lead us to further investigations if raised and can be useful but do not have a high specificity for cancers

In patients with a persist raise ESR and where other tests are negative the possibility of requesting a CT scan of chest and abdomen was considered.We could think of two other cases where this would have speeded up cancer diagnosis.

In patients over 50 with a single episode of painless rectal bleeding a referral for investigation should be made, although this would be outside the 2WW rule guideline.


Learning, Messages and Reflections – Ovarian Cancer SiteLearning, Messages and Reflections – Ovarian Cancer Site

Extracts from the audit narratives relating to Ovarian Cancer Site

1When prescribing HRT it is important to share the risks in easy understandable terms with the patient

When requesting investigations it is important to understand the results and what subsequent action is required

There should be consistency across practice in sharing risks with patients and what tools can be used e.g. the national prescribing centre tool

2

Unexplained anaemia ,even if it is only mild, always warrants prompt further investigations to rule out underlying malignancy

3 Beware of urinary symptoms in the absence of a UTI in female patient

Consider a gynaecology reason for abdominal urinary symptoms

Use the CA125 test in line with NICE guidelines

4 Beware atypical presentation of urinary symptoms in women

5There is a known association between ovarian cancer and dyspepsia

The CA125 test will be used more frequently in appropriate circumstances

6Can be very difficult to pick up symptoms early in patients who have addictions to alcohol or drugs

Be vigilant about other physical illnesses in these patients .

7

Acute ascites is not a very common presentation in primary care.

Picking up the phone is a useful way of getting an out patient appointment and an urgent scan - we don’t always have to depend just on the form


Learning, Messages and Reflections – Ovarian Cancer SiteLearning, Messages and Reflections – Ovarian Cancer Site

Extracts from the audit narratives relating to Ovarian Cancer Site

8For patients with learning disabilities an annual health check can pick up their medical problems

9

All females over 50 years old with bloating and vague abdominal symptoms should have a CA125 according to new NICE guidance


Learning, Messages and Reflections – Prostate Cancer SiteLearning, Messages and Reflections – Prostate Cancer Site

Extracts from the audit narratives relating to Prostate Cancer Site

1Consider checking alpha foetal protein and HCG tumour markets for patients with hydrocele.

Check PSA in older men with urinary symptoms.

IPSS may be helpful in assessing urinary symptoms in older men

2

When thinking about making a urological referral a DRE is appropriate to ensure that all possible problems can be considered

3Practices should have a recall system in place for appropriate PSA monitoring every 6 months.

If stable NICE guidance suggests a watch and wait system 6 – 12 months

The practice has instigated a system for recall. Should an abnormal test result be received the GP will enter recall dates onto the practice system.

4

There should be a standard series of blood tests requested in all cases of vertebral collapse, even if the x-ray suggests it is not suspicious

The blood tests suggested are FBC, ESR, CRP, bone biochemistry, myeloma screen, vitamin D and PSA

5

There should be prompt referral to urology of any PSA > 2.5 in over 50s and > 4.0 in over 60s as stated in local guidelines

The decision to measure PSA in the absence of symptoms is still controversial

6All men presenting with lower urinary tract systems have a PR and are investigated in line with NICE guidance


50

RecommendationsRecommendations

RecommendationsRecommendations


1 2 3 4This report should be read in conjunction with ‘Improving Diagnosis of Cancer – A Toolkit for General Practice’ Mitchell et al - 2012, which provides a synthesis of the data from 2 rounds of the National Cancer SEAs.

This can be found on the National Cancer Action Team website:

http://www.ncat.nhs.uk/sites/default/files/work-docs/Improving%20Diagnosis%20Toolkit%20for%20GPs.pdf

Many of the audits in this project were of a very high standard. The GP Cancer Leads may wish to consider how these could be used as ‘case studies’ or examples when reporting to or encouraging other practices to participate

Although audit is an integral part of General Practice some practices may benefit from support in setting up a regular audit programme. This should include ‘tips’ on how to facilitate the team discussion and creating an open and inclusive environment – elements that are crucial to any quality improvement process as it is only when this is achieved that team learning and change can occur

The North of England Cancer Network and the GP Cancer Leads should encourage participation in the National Audit of Cancer Diagnosis in Primary Care and Cancer Significant Audit (SEA).

This RCGP pilot will offer anonymised external peer assessment of your significant event analysis of cancer diagnosis.

The North of England Cancer Network is a participating network and this provides an opportunity to receive feedback on your SEA audits which can go towards your personal appraisal portfolio.

Further information is available from the Network





AcknowledgementsAcknowledgements


AcknowledgementsAcknowledgements

Name Organisation

The Cancer in Community Group NECN

GP Cancer Leads NECN and MacMillan

Suzanne Thompson NECN Cancer Modernisation Manager

Joanne Preston NECN Service Improvement Facilitator

Dr Nari Pindolia NECN

All Participating GPs and their Practices



54

gp significant event audit report north of england cancer network december 2012

Documents

cancer lung cancer

report cancer

cancer sites

timely diagnosis of

nhs cancer plan

cancer reform strategy

primary care audit study

audit process