Two-week referrals a cocktail for complaints

Time-dependent, stressful and often scary, 2-week referrals can be a cocktail for complaints. Dr Rachel Birch from MPS presents a roundup of useful advice on two week referrals for an all too regular clinical presentation.

Many patients are likely to be aware of the NICE guidelines for the recognition and referral of suspected cancer. Certainly, public health campaigns and the media have helped to educate patients on potential early warning signs for cancer.

As such, some patients may come in specifically asking to be referred under the 2-week rule for further investigation. However, others may have no idea that their chronic cough or postmenopausal bleeding could be a symptom of cancer and might be shocked when a 2-week referral is mentioned.

This is a sensitive area to tread, and even more important for locum GPs, who may be seeing the patient for the first time and be unaware of significant family history or the loss of a previous partner or friend to cancer.

How to bring up the subject of a 2-week referral?

It is often a difficult task, to suggest to a patient that their symptoms might represent cancer. It may be tempting, in some situations, to simply tell the patient that you will refer them for “further tests”. This may be a reflection of the doctor’s own uncertainty or a genuine desire not to upset the patient.

However, the GMC expects doctors to be truthful and open with patients and ensure that patients have sufficient information to provide consent for a 2-week referral. How much information you share with patients may vary, depending on the patient’s wishes and discussion should be tailored to the individual. The GMC states that doctors should not make assumptions about:

How much information you share with patients may vary, depending on the patient’s wishes and discussion should be tailored to the individual. The GMC states that doctors should not make assumptions about:

  • the information a patient might want or need
  • the clinical or other factors a patient might consider significant, or
  • a patient's level of knowledge or understanding of what is proposed.

Therefore, at the very least, the doctor should advise the patient that they are referring them under the “2-week suspected cancer pathway”, as per guidance for their particular symptoms.

Do I have cancer doctor?

This is an inevitable question that some patients will ask. It takes time to answer this question sensitively and patiently. Understandably, the patient might be shocked to learn that their symptoms might be indicative of cancer and may not have considered this as a possibility.

Whilst their symptoms may meet the criteria for 2-week referral, it is not the case that every patient will be diagnosed with cancer. In fact, the majority of patients referred under this pathway do NOT have cancer. This can be enough, sometimes, to reassure patients whilst they are waiting to be seen.

I have heard some colleagues refer to the “2-week rule” as being designed to “rule out” cancer, and again, this can form a useful discussion with the patient.
It is important to provide the patient with as much information as possible at this stage, and if you simply don’t know, it is OK to say that.

If a patient is particularly upset or concerned, consider offering to see the patient at the end of surgery with their relative or friend, to go through their concerns in more detail.

What to expect from a two week referral?

It can be helpful to give the patient some idea of what to expect at a certain clinic. For example, if referred under the suspected lower GI cancer pathway, they are likely to require a sigmoidoscopy at their first appointment; whereas if they are referred under the suspected breast cancer pathway, they will mostly likely be offered a mammogram.
Providing patients with information can greatly reduce the anxiety associated with such referrals- the greatest distress can often come from fear of the unknown.

As a locum GP, ensure you are familiar with local arrangements for suspected cancer pathways.

Some areas have written information for patients and it is a good idea to try to obtain some copies of these in advance of starting a locum post.

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How to manage inappropriate requests for 2-week referrals?

Patients may sometimes come in demanding to be referred under the 2-week rule, as they have read about this in the paper or a friend has been referred in this way.

Doctors have a responsibility to ensure that referrals are made appropriately and honestly. You should first assess the patient and explore their reasons for the request for a 2-week referral. If they do not meet the criteria for 2-week referral, you should explain this to them and the reason why.

It is important not to refer patients inappropriately as the resource is available for patients who meet the specific national criteria. If the clinics received numerous inappropriate referrals it would impact on the waiting times and may adversely affect those patients at highest risk of cancer.

Although the patient may not be eligible to be referred under the 2-week pathway, if you feel they should be referred urgently, you should discuss this with the patient and the steps you will take to emphasise to the specialist the urgency of the referral.

How to prevent missed two week referrals

Dictate or send the referral electronically with the patient in the room, so that you can both be satisfied that the referral has been made.

Let the patient know what to expect- the national target for cancer referrals is that patients are seen within 2 weeks of referral, although in some areas the wait can be slightly longer.
Ask the patient to contact the practice if they have not received an appointment within 3 weeks.

Devise a system so that you can track your 2-week referrals and ensure they are seen in secondary care and a letter sent back to the practice. If you are leaving the practice, handover the patient details to a GP partner so that they can do the same.

This article first appeared in The Sessional GP magazine.

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