GPs who fail to spot cancer could be named. No government could have designed a better perverse incentive to over investigate and over refer.

BBC News 29th June 2014 reports: GPs who fail to spot cancer could be named (In England only!)

This idea, presumably by managerial zealots who are not allowed to mention the “R” word, is their suggestion for deflecting some of the criticism which is going to come their way. Most of it, really and truly, should be directed at the politicians…. The single most important factor determining outcome is how soon you present to your doctor. In lower social class areas people present later and at A&E departments. These are the areas where recruitment is most problematic… is this suggestion meant to help recruitment? Once embedded as a Performance Indicator, think of the perverse incentives to over investigate and to over refer? And the implications on the Regional Health Service budgets? Better to let GPs continue to gatekeep in the most efficient system in the world, which is the envy of most ministers of health.

GPs with a poor record in spotting signs of cancer could be publicly named under new government plans.

Health Secretary Jeremy Hunt wants to expose doctors whose failure to spot cancer may delay sending patients for potentially life-saving scans.

Labour called the idea “desperate” and accused Mr Hunt of attacking doctors.

The Royal College of GPs said it would be a “crude” system and one that could lead to GPs sending people to specialists indiscriminately.

It warned this could result in flooding hospitals with healthy people.

The move is part of the health secretary’s plans to make the NHS more transparent.

Ranking GP surgeries on how quickly they spot cases of cancer and refer patients for treatment is among proposals being considered….

No government in any UK Region could have designed a better perverse incentive to over investigate  and over refer. I doubt it will be a runner..

A biased report supports the British Health Services- and claims our overhead as 3.4%. Trusts vary greatly, and probably don’t know..

Update 30th June 2014 Times Letter from Dr Sarah Murray:

GPs may see 50 potential cancer victims in one day, and they have to rely on their skill to make the best diagnoses

Sir, GPs do not miss cancer through wilful negligence or incompetence (June 30). Each GP sees about 50 presentations of potential cancer symptoms every day. The only way to be certain of never missing a diagnosis would be to refer every one of these for a consultant opinion or further investigation. A CT scan for every headache. A colonoscopy for every tummy ache. A chest X-ray for every cough. A biopsy for every mole or swollen lymph node. This would not be a measure of a “good” GP. The NHS would collapse within days and patients would be harmed by over investigation (radiation-induced cancers, unnecessary surgery etc). GPs use their clinical acumen, time and simple investigations to make a judgment about appropriate referral. Inevitably a few early cancer presentations will be missed — it is tragic, of course, for individual patients when this happens, and we feel dreadful too — but these are a tiny percentage of the decisions made every day. It is a reflection of the real problem that cancer is not a single disease with a simple diagnostic presentation, and not a reflection of poor GP quality. It is impossible to have an accurate cancer diagnosis in every single case within the current system and bounds of knowledge.

Dr Sarah Murray

Yelverton, Devon

Update 1st July 2014 from The Derby Telegraph: Shaming plan would cripple NHS, says Derbyshire doctor

Update 3rd July 2014: GP diagnosis and cancer of the Pancreas. Letters in The Times:

Survival rates for pancreatic cancer have hardly improved in 40 years

Sir, That one extra case which Dr Mark Porter claims could turn his practice from excellent to worst performance (“The NHS has a problem with cancer survival rates but naming and shaming GPs won’t help”, July 1) could have been my daughter’s.

Had her general practitioner been more aware of the “suspicious symptoms” which she presented to him four or five times and had she been referred for testing, she might have had a chance of survival.

Had the out-of-hours hospital doctor had more imagination than to say “I can feel a lump, you’re constipated”, her chances might have been greater.

The statistics of which Dr Porter is so wary represent lives, and surely a life saved is worth many unnecessary tests.

GPs should be accountable, and the public should be aware of how well they are performing. Earlier diagnosis, using the tools available over the weekend and for longer weekday hours, would in the long run avoid costly last-ditch attempts at care. The “unnecessary tests” reassure far more effectively and quickly than repeated visits to a GP.

The survival rate for pancreatic cancer, from which my daughter died, has hardly changed for 40 years, with only 4 per cent of the 8,000 people diagnosed each year surviving more than five years.

When are things going to change? We do not need the complacency of GPs worried about statistics, but concern by GPs to save and protect the lives in their care.

Celia Goodman

Twickenham

Sir, Mark Porter’s defence of GPs in the face of yet another secretary of state for health who seeks to blame others for “mistakes” and shortcomings without taking responsibility, will be applauded by his peers but misses the point.

In the case of pancreatic cancer — which suffers from almost universally late diagnosis, few treatment options and has an exceptionally high mortality rate — GPs tell us they need help understanding the disease.

In this sense, a number of groups are at fault. The GPs for not coming forward and seeking a better understanding, secondary-care surgical and medical oncologists for not making more opportunities available for GPs to learn, the NHS bureaucracy for not being able to think outside the box, and politicians for, well, getting in the way.

Although pancreatic cancer in the UK is only the tenth most common cancer it is the fifth (soon to be the fourth) biggest killer. The average survival time post diagnosis is six months, and fewer than 4 per cent of those diagnosed survive for five years, and those two statistics have hardly changed in 40 years, unlike the (fantastic) improvements in the statistics for breast cancer, leukaemia and some other
cancers.

Pancreatic cancer is a prime example of where GPs need help, not shaming, but health professionals continue to stay in their bunkers.

For pancreatic cancer patients and their loved ones the issue is rarely about any meaningful period of survival, but earlier diagnosis will give families more time together in a situation where days and weeks are like gold dust.

More leadership is required.

Gerald Coteman

The Elizabeth Coteman Fund (Pancreatic Cancer Support & Research), Cambridge

How is pancreatic cancer diagnosed?
Mayo Clinic: Pancreatic cancer Tests and diagnosis – Diseases and
Treating pancreatic cancer : Cancer Research UK Pancreatic Cancer Treatment (PDQ®) – National Cancer

And that’s all without the “frontier” issues: Patient in Wales fights to be treated in England – I wonder what the outcome was?

This entry was posted in A Personal View, Perverse Incentives, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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