Guidelines or tramlines? Putting cancer guidance back on track.
March 1, 2016
“Does this make them good doctors or bad doctors?” was my favourite response to the Pulse article “GP’s are bending the rules on cancer guidelines to benefit their patients” that discussed our BJGP article on international variation in cancer guidelines and the differences in how GPs follow them. It’s a good question!
Margaret McCartney wrote a relevant viewpoint in the British Medical Journal back in 2014. She immortalised the words of David Haslam (then Chair of the guideline developers NICE) at the NICE conference. From the horse’s mouth, he said- they are “guidelines not tramlines”. You could feel the collective sigh of relief from all the GPs (including me) who had deviated (even slightly) from the NICE guidelines (once or twice).
You might, then, find it strange that in Oxford that we’ve been redeveloping the 2-week-wait (urgent referral) cancer pathways with the Oxfordshire Clinical Commissioning Group so that they match up with the suspected cancer guidelines released by NICE in July 2015. This has been no mean feat! (and is not exclusive to Oxford). There were over 200 recommendations and each form requires sign-off from our hospital colleagues before being used by the 632 GPs working in the 72 practices across Oxfordshire. Hospital specialists have reservations about NICE, expressing concerns that tests being recommended inappropriately and too many patients being referred without cancer will further overwhelm their already overstretched clinics. So, if this is true, why bother at all?- specialists dislike the new guidelines and GPs don’t take any notice of them.
The 2015 guideline includes three major leaps forwards to overcome the fact their 10 year-old predecessor led to the detection of under 50% of cancers: 1) they lower the risk of cancer at which GPs should refer or test their patients, meaning patients can be investigated earlier- something patients want; 2) they are based on research conducted on General Practice patients, as relying only on traditional “red flag” or “alarm” late symptoms seen in specialist clinics means that cancers may be caught too late or present as an emergency; 3) they are based on symptoms and not just cancer types, as some symptoms like weight loss and fatigue are common to many cancers and are missed by cancer based guidelines. So referrals may go up, but the previous system was not working.
Our research was conducted using International Cancer Benchmarking Partnership data before the 2015 NICE guidelines were released. An interesting finding was that nine out of 10 UK GPs reported they would ignore the clinical guidance if they suspected their patient had cancer but their symptoms did not fit the criteria for urgent referral and refer them for tests anyway. 20% of these said they would record the patient’s history in such a way that allowed them to fit the guidelines for urgent referral. As our data suggest that GPs would sometimes already operate outside the guidelines, perhaps the lower threshold used in the new guideline more closely represents current GP best practice.
What if the specialists are right? Perhaps the new referral threshold has been set too low. The guidance will certainly need to be refined as more research is done into how patients with symptoms of possible cancer present to GP, which tests a GP should use first, and whether GP is the best place for them. Innovative work is already underway to investigate new models of care as this is a space where specialists, GPs, and the guideline developers must (and will) meet to conduct collaborative research. After all, research is needed that spans primary and secondary care (as patients move through both). All too often it seems to be an either or situation.
So, returning to the initial question, are they good or bad doctors? My personal view is that no guideline can replace the clinical intuition gained from consulting patients, and guidelines attempt to formalise good clinical decision making but they are no catch all. If the majority of GPs are acting outside of a guideline it strongly suggests that the guidance is not fit for purpose. Let’s revisit this in 10 years when the changes are full steam ahead.
Brian D Nicholson is a GP, Research Fellow of CEBM, and an NIHR Doctoral Research Fellow researching evidence-based cancer monitoring and diagnosis in primary care.