Exclusive GPs in Hampshire have raised concerns about hospital specialists downgrading their cancer referrals, a measure which has caused ‘considerable alarm’ due to the risk of missed diagnoses.
Hampshire and Isle of Wight ICB is using the advice & guidance (A&G) process for cancer referrals, Pulse has learnt.
GPs have told Pulse that the effect of this is that fast-track cancer referrals are being received as A&G and being downgraded by hospital specialists, which could bring an increase in risk of missed cancers.
They argued that this goes against national cancer guidance, which says that referrals should not be downgraded without a discussion with the referrer.
Pulse was told that this is happening for cancer referrals to specialties including gynaecology, dermatology, lower GI, urology and respiratory.
A Hampshire GP, who asked to remain anonymous, said that they had a cancer referral downgraded by Hampshire Hospitals when they referred a woman who presented with menorrhagia and was also reporting post-coital bleeding.
They said: ‘On examination, she had an abnormal-looking and feeling cervix. The combination of examination findings and post-coital bleeding meant I referred as a two-week wait.
‘I got a response from gynaecology advising that I should re-refer to the menstrual disorders clinic. I responded explaining that whilst this might be appropriate longer term, my reason for 2WW referral was actually regarding cervical cancer.
‘I have now had further correspondence advising that the referral has been downgraded and the patient is planned to be seen in the menstrual disorders clinic in early 2025.
‘I now have a patient who is worried that she may have cancer with no review for many months, and I am concerned about the medicolegal risk and where that sits.’
Other examples shared with Pulse of rejected or re-triaged cancer referrals at Hampshire Hospitals included:
- A urology referral for frank haematuria, rejected despite the GP saying blood tests had already been requested
- A lower-GI referral rejected as the patient was ‘not available in the next two weeks’. The GP said that the dates the patient was away were already noted on the referral form
- A respiratory referral for haemoptysis rejected despite chest X-ray and blood tests had already been requested at time of referral.
Another GP, who also wished to remain anonymous, told Pulse that a skin cancer referral he made for one of his patients was downgraded by the specialist at Portsmouth Hospitals, with confirmation that this happened as ‘agreed with commissioners’.
He said: ‘I thought this was a mistake, so I raised it and flagged it with both the hospital dermatology team and the ICB, and their response was to confirm that it wasn’t a mistake and that the ICB had instructed the hospital team to do this, and that that was essential in enabling them to meet their waiting time targets.
‘It seems to go against the national cancer framework, which sets out that a referral can only be re-triaged or downgraded with agreement and communication with the referrer, and that without that, the expectation is that the patient is offered a video or a face-to-face consultation.’
He added that one of the concerns around this is that forms used to refer are ‘very simplistic’ because they are meant to facilitate quick referral.
‘So actually there isn’t the opportunity to provide lots of information. I guess the ability with dermatology is to be able to provide photos, but there is no standard or framework over what constitutes good medical imaging.’
He also pointed out that this has been implemented ‘without GP engagement’, so GPs and patients are ‘unaware’ of how they need to change their approach to this interface.
He added: ‘For the GP, the result is an increase in medicolegal liability as the decision to downgrade is based purely on the information provided by the GP. For the patient, there is no guarantee of a hospital specialist assessment.
‘The ICB’s action feels like an increase in risk of missed cancers with patients, and there is concern that GPs will be exposed to the implications.’
Joint CEO of Wessex LMCs Dr Laura Edwards said local GPs are ‘very concerned’ that this does not fit with national cancer guidance and that the risk ‘is left with GPs’ in this scenario.
Dr Edwards told Pulse: ‘Wessex LMCs believes that advice and guidance should be part of the options available to support GPs in caring for their patients and we know our GPs value having this available when it is used by both sides in the right way.
‘Wessex LMCs does not support a scenario in which a GP cannot make a direct referral: from a clinical perspective, and in the context of the ongoing relationship between a patient and their GP, the LMC believes that if a GP wishes to make a referral for a specialist opinion given to the patient directly by the specialist, this should be accepted.
‘This is particularly true for cancer referrals. We have heard concerns raised by our GPs about downgrading of cancer referrals from a number of specialities which has caused considerable alarm.
‘We are very concerned that this does not fit with national cancer guidance and that the risk is left with GPs in this scenario and we are concerned about the potential for patient harm.
‘National cancer guidance says that referrals should not be downgraded without a discussion with the referrer.
‘We will continue to raise our concerns with the ICB, the providers and the Wessex Cancer Alliance about departure from this national rule. We look forward to working with all parties to find a mutually acceptable solution.’
The ICB told Pulse that they do not mandate the use of A&G for specialties, but that they support the use of the pathway for cancer referrals.
A spokesperson for Hampshire and Isle of Wight ICB said: ‘NHS Hampshire and Isle of Wight supports the use of advice and guidance to help our GPs to access the most appropriate pathway for their patient and to reduce waiting times for patients.
‘Some specialities use the A&G pathway to create a single point of access to enable patients to be given access to the right clinic first time.
‘The use of A&G also can help with an early cancer detection as routine referrals can be quickly upgraded onto a two-week wait (2WW) pathway.
‘The option to refer a patient using the two-week wait pathway is still available and continues to be routinely used.
‘Patient safety remains our key priority, and we continue to support discussions to ensure the safe delivery of these pathways.’
A spokesperson for Hampshire Hospitals said: ‘Providing early cancer diagnosis and treatment is a priority for Hampshire Hospitals. While we can’t comment on individual cases, there are times when preliminary tests are required before further progress can be made and we work with our system colleagues to ensure these are carried out in the right way as quickly as possible.’
A spokesperson for Portsmouth Hospitals University (PHU) NHS FT said: ‘At PHU early diagnosis and treatment for cancer is a priority. We use a single point of access for all dermatology referrals which allows us to manage all referrals including the 2WW A&G pathway.
‘This can help us identify cancer earlier in the process as routine referrals can be upgraded to a 2WW pathway. All referrals are reviewed by a senior clinician and placed on the most appropriate pathway. If a referral is downgraded, we aim to discuss this with the referrer.’
A Wessex Cancer Alliance spokesperson said: ‘Wessex Cancer Alliance works closely with ICB colleagues to ensure patients are quickly accessing the right pathway and any suspected cancer patients are prioritised appropriately.’
Earlier this year, GP leaders raised concerns that NHS England had encouraged ICBs to adopt an ‘advice and refer’ model, effectively replacing traditional GP referrals and adding barriers for patients in accessing secondary care.
NHSE guidance has promoted adoption the use of the ‘advice and refer’ model, which means all referrals or advice requests from GPs ‘come in through one route’ and directly bookable appointments are ‘discouraged or removed’.
Under this service, all referrals are then ‘triaged’, allowing hospitals to reject referrals and send them back to GPs with advice. But NHSE leaders have told Pulse that there will be no national mandate for GPs to use advice and guidance in a certain number of cases.
Simples
WTRR Collective action
” no acceptance of rejection and advice in place of a referral ”
‘A Hampshire GP had a cancer referral downgraded’ it is stated. I thought that it is essential that the earlier a cancer patient gets seen, the better will be the outcome. Does the GP know exactly who ( FIND OUT ) at Hampshire Hospitals did the downgrading: for example was it even a Gynaecologist or a Doctor at all; should the GP speak to the top Gynae person at the hospital to find out who it was who made this apparently uncaring, dangerous downgrade and, of extra importance, how many other patients in that area are similarly affected? This could amount to a very serious NHS Inquiry. Alternatives to get action may include higher involvement by reporting, as a highly important, rapid action matter, to the GMC and MDU or other Defence Org. Also, this is so serious that a TV company like the BBC or a national newspaper would no doubt want their reporters to do more digging,( hopefully before the graves of too many cancer patients get dug ); even one is too many, and is someone’s wife, sister, daughter or mother, for example. If this injustice has happened to just one GP and one patient, it is so demoralising and to what depths has the NHS sunk? Who’s to say another mistake by Hampshire Hospitals will happen in 2025, that leads to an even more delayed hospital appointment next year , or misdirected mail or a series of errors that will lead to an inoperable worst case scenario. I feel very sorry for this GP who seems to be doing their best, but go further and FIND OUT more and report this tragic situation: before more innocent women die. Underfunding should not mean this cancerous NHS situation occurs. Another sad thing is the top Gynae doctor may have disastrously taught their underlings to do these downgradings of cancer, sowing the seeds of more NHS failings, quite possibly, and who takes ownership of the failure or was someone at the hospital acting autonomously perhaps, or a PA? Alarm among GPs is terrible and a number of specialities affected. W Streeting (Health Sec), other MPs, NHSE and K Starmer PM should sit up and take immediate action too: have they all been instructing hospitals in tragic, improper methods: to meet some sort of targets perhaps? So terrible.
Watch as the NHS withers and dies. Politicians focused on cuts and privatisation and a system that facilities it. Not long before the UK becomes a failed state.