Quality in Primary Care Open Access

Introduction

In 2000, national cancer guidance was circulated to primary care organisations to build on the work undertaken through the Calman–Hine programme, strengthened more recently by National Institute for Clinical Excellence (NICE) guidance on primary care referral for patients with suspected cancer.[1–3]

Within North East Lincolnshire, our approach has been to see the national guidance as an opportunity to ‘localise’ or practically integrate current evidence in order to develop locality guidelines within care pathways. We have utilised a similar approach for the implementation of the National Service Frameworks, for example that for coronary heart disease. This article describes the development and the positive impact of our approach.

North East Lincolnshire Primary Care Trust (PCT), established in 2001, has a population of approximately 165 000 with 34 local practices. The practices, to sup-port development, sharing of good practice and com-munication, are aggregated together into populations of around 20 000 as seven primary healthcare teams; one practice is a double primary healthcare team. It is served by Diana Princess of Wales District Hospital which is part of Northern Lincolnshire and Goole Acute Trust.

Engagement of the local health community

The ‘localisation’ of the National Cancer Guidance has been implemented by using a three-step process as detailed in Box 1.

Key characteristics of the locality guidelines and care pathway

User friendly

As a health community we wanted guidelines that were practical and relevant to day-to-day practice.

Therefore, the majority of the guidelines developed contained within a single sheet of A4 or, where linked to a referral proforma, the referral proforma is on one side of the sheet with the supporting guidelines on the flipside. As well as being available in paper form, they have been made available electronically to local prac-tices. We anticipate that within the ‘Choose & Book’ initiative they will become integrated as part of the electronic referral pathway.

Timely referral

The intention of the care pathway, as well as support-ing appropriate local primary care practice, was to facilitate an effective system for timely referral for patients suspected of cancer. Both the guidelines and the utilisation of referral proformas have been used to support this.

Appropriate primary care management

In addition, the initiative also looked to support, as appropriate, ongoing primary care management. Guidelines were used to endorse the appropriate ‘wait and watch’ policy, perhaps best highlighted in the guidance relating to management of patients presenting with potential colorectal pathology.We also enhanced primary care access to diagnostics, including ultrasound, further supporting management within a primary care setting of patients such as those presenting with haematuria and proven urinary tract infection. Primary care access to transvaginal scanning has been facilitated by guidance on postmenopausal bleeding which is dependent on endometrial thickness.

The health community approach

Development of the locality skin cancer care pathway provided an opportunity to integrate and further enhance the provision within primary care, provided by the longstanding general practitioner (GP) minor surgery group, with that provided by the specialist service. This care pathway facilitated the co-ordination of resources within the locality, maximising the benefits to patient services.

Locality guidelines established

As a locality, we selected, over a 3–4-year period, to develop locality guidelines for the following cancer areas:

• breast
• lung
• upper and lower gastrointestinal (GI)
• skin
• gynaecological
• urological
• testicular
• head and neck.

Due to the small numbers and the range of presentations, it was decided not to develop locality guidelines (in addition to the national cancer guidance) for cancer affecting children, the brain or central nervous system, or sarcomas. We initially took the same approach for haematological cancers, but recently we have begun to develop guidelines for some haematological cancers, again looking at the practical management within a primary care setting.

Referral proforma

For some cancers it has been deemed appropriate to develop referral proformas as a practical mechanism to support utilisation of locality guidelines as well as facilitating timely specialist referral. Referral proformas have been developed for breast, colorectal, and upper gastrointestinal cancers, as well as the primary care element of the skin cancer service. Although the referral proformas initially were optional, given their ease of use they have become the standard tool for referral.

Clinical guidelines within developing care pathways

Clinical guidelines provide opportunities to maximise the management of patients in line with current evidence, and to co-ordinate healthcare resources. We used the opportunity of development of locality guidelines to highlight our local philosophy on guidelines as expressed by the Royal College of Radiologists in 1990, in their review of guidelines ‘a guideline does not place a constraint upon clinical practice, but rather promotes the concept of good practice against which the management of the individual patient can be considered’.[4]

Implementation of locality guidelines

The guidelines were developed over a 3–4-year period beginning with breast and colorectal cancer, which represented conditions with the highest referral and diagnostic rate. Following the success of this approach, a similar process was adopted for other cancers. Following the introduction of the guidelines we have been keen, as a health community, to ensure that they do not sit on the shelf gathering dust but, as intended, are practically useful. We have looked to support audits both at the practice as well as PCT level to reflect three principal areas of review:

•the clarity and appropriateness of the current referral proforma and guidelines
•the effectiveness of the guideline in identifying patients with the relevant cancer
•utilisation of the guideline within the overall care pathway.

We have encouraged practices to review ‘conversion rates’ of urgent two-week-wait (2WW) referrals to cancer diagnoses,4 and to use the significant event review programme as a positive way to reflect on non-2WW referrals that are later demonstrated to have cancer.
In 2004, in collaboration with our local acute trust, we undertook a prospective audit of the appropriateness of urgent 2WW referrals for breast and gynaecological cancers. Over a three-month period, the receiving con-sultants for urgent 2WW referrals for breast and gynaecological services reviewed each referral and, where this appeared to fall outside locality guidelines, wrote to the GP highlighting it as a potential non-compliant referral and inviting a response. The referred patients were managed as usual. All but one GP replied promptly to the letter and provided feedback which highlighted a degree of misunderstanding with regard to the 2WW referrals and non-cancer urgent or ‘soon’ referrals. In the light of this, the referral proforma and guideline for the breast service were updated.

Outcomes and value of locality guidelines

Ownership and utilisation

Our intention has been to ensure professional own-ership and confidence in locality guidelines which has led to a high level of utilisation. Practice-level local development initiatives, including practice cancer action plans, have further supported this. Most GPs have welcomed the referral proformas including the guide-line and found them to be useful, in particular the concept of having the guideline on the flipside and therefore easily to hand. The layout of the referral proformas has been standardised, also improving uptake. However, one or two doctors have found this to be impersonal. Although retaining the facility to refer to a named consultant, the proformas have provided a pooled referral as an option and a practical way of addressing the two-week referral deadline.

The breast cancer referral pathway was launched at a service review meeting in 2000, and its imple-mentation was reviewed 18 months later. Audits showed good adherence to the guideline, and feedback revealed strong support for the referral proforma. At the suggestion of those present it was accepted that rather than optional utilisation of the proforma it would be adopted as standard for referral to the breast service. Over the following years the guideline has been updated on a number of occasions, the current version is given in the Appendix.

Collaboration

The work to date has led to significant sharing of experiences and outcomes across practices within the primary care trust. The establishment of project teams across primary and secondary care has provided the opportunity for close working and greater awareness of mutual objectives and challenges between clinical and managerial colleagues. The locality guidelines would not have become a reality without the active and ongoing support of the lead specialist consultants.

Indicators of added clinical value

If implementation of locality guidelines is to have added value, the most important consequence is their impact on service delivery to patients. A key indicator is that of conversion rates of urgent 2WW referrals to cancer. Conversion rates are not simply a result of guideline implementation in isolation, but rather reflect related issues such as awareness, access and professional relationships across the primary/second-ary care interface.

Table 1 details the conversion rates of the cancer areas considered within the national cancer guidance. It provides the information for North East Lincoln-shire PCT referrals within the calendar year 2004. In addition, on the right side of the table, additional data are provided, highlighting the range of conversion rates within Humber and Yorkshire Coast Cancer Network and the average conversion rate.

Interpretation of conversion rates

Conversion rates are determined by the quality of the data entered into the Cancer Waiting Time database. For all cancer areas where a locality guideline has been developed, the conversion rate is above the average for the network. In five out of the eight cancers, the conversion rate achieved was the highest in the net-work.

Of the three areas where, given the small numbers and variation of presentations, a locality guideline was not developed, conversion rates were zero. However, it is important to qualify these results by considering the very small number of referrals involved, the range of presentations and the likelihood, as was our original consideration, that the introduction of a locality guideline may not have had an impact.

What is the value of conversion rates?

Following discussions within and outside our cancer network, there appeared to be no national data show-ing conversion rates for each locality and cancer type, nor were we aware of any indicative targets.

The intention of developing locality care pathways was to raise the profile of the national cancer guidance, and provide a practical framework that would allow local primary care clinicians to target patients present-ing with likely significant pathology. Conversion rates could be used as a measure of how sensitive such guidelines are, but high conversion rates may also reflect guidelines that tend to detect more advanced cancers. The objective of the guideline is to identify a cancer presentation within a primary care setting, at a stage that is most amenable to treatment. Therefore, although conversion rates can be a useful guide, other indicators need to be considered, which may include cancer diagnosis presenting outside the 2WW ar-rangements, and the outcome of cancer treatment, including survival rates.

Benefit of the review of conversion rates

Conversion rates of 2WW referrals to cancer are one indicator that we can independently compare against other localities. From an NE Lincolnshire PCT per-spective it has provided the opportunity for two key outcomes:

•positive feedback to local primary and secondary care clinicians with regard to the work they have jointly undertaken to date

•generating local discussion on what should be done next.

However, there is also an opportunity within our cancer network and beyond to generate discussion on the following:

• benefits of ‘localisation’ of national guidance and, as a consequence, a positive impact on local clinical engagement

• the added value of local guidelines:

  what is the value of conversion rates?

  is there an indicative target?

what should be the quality assurance framework to support the implementation of clinical guidelines within the emerging care pathways?

The commissioning focus

The last five to six years have seen a significant investment in cancer services, particularly in second-ary and tertiary care, following the introduction of The NHS Cancer Plan.[5] Within our cancer network there is an acknowledgement that, given the significant chal-lenges faced by secondary and tertiary care, this focus has been appropriate. The introduction of the 31/62-day cancer target promotes further devel-opment of specialist services. However, it also provides the opportunity to refresh the primary/secondary care interface and review the utility of referral guidelines to enable the achievement of the 31/62-day target.

We are currently in an organisational consultation period, following which it is anticipated that the majority of PCTs will reconfigure. We hope to utilise the change to refresh the primary care focus. It is essential that the future commissioning focus, as well as addressing the secondary and tertiary services, supports primary care management and the interface between primary and secondary care.

Conclusion

Locality guidelines have been used to support effective and appropriate primary care management, timely access to diagnostics and, where clinically appropriate, prompt referral within the 2WW arrangements. The process is one of ongoing review and refinement, for example, in recent months, following review of the colorectal care pathway, we are now piloting a ‘straight to test’ arrangement, further utilising skills within primary care, while reconfiguring the care pathway to target probable cancers, hence, maximising the benefit to our patients of the specialist service.

References

1. NHS Executive. Cancer Referral Guidelines: referral guidelines for suspected cancer. HSC 2000/013. London: NHS Executive, 2000.
2. Calman K and Hine D. A Policy Framework for Com-missioning Career Services. London: Department of Health, 1995.
3. National Institute for Clinical Excellence. Referral Guide-lines for Suspected Cancer. London: National Institute for Clinical Excellence, 2005.
4. Royal College of Radiologists. Making the Best Use of a Department of Clinical Radiology. London: Royal College of Radiologists, 1990.
5. Department of Health. The NHS Cancer Plan: a plan for investment, a plan for reform. London: Department of Health, 2000.

Conflicts of Interest

None.