NHS Resolution publishes report on delayed diagnosis of cancer in GP claims

Rebecca Taylor-Onion, Alison Brennan and Paul Thomson provide a summary of NHS Resolution’s report on patient safety issues following a thematic review of GP indemnity claims.

NHS Resolution recently published a report following a thematic review of GP indemnity claims. The report considered how GPs can play their part in improving cancer diagnosis. The report states there are 950 new cancer diagnoses made each day in which general practice “plays a crucial role in the patient pathway, from first contact until diagnosis, and it is recognised as the gatekeeper of access to specialist diagnostic imaging and specialty cancer services.”

NHS Resolution says GPs are “referring people on urgent suspected cancer pathways in record numbers, leading to millions of people being diagnosed with and beginning treatment for cancer in England.” The report examined 105 closed settled claims concerning delayed cancer diagnoses in general practice over a seven-year period.

Whilst the report acknowledges most GP consultations are safe, and the claims data does not capture all instances of delayed diagnosis or fully represent the risks and challenges faced in clinical practice, it provides the following statistics:

• 40% of cancer diagnoses were made following routine referrals or emergency department attendance.
• 65.7% of patients were diagnosed with stage 3-4 cancer, compared with national early diagnosis rates of around 54% for stages 1-2.
• 73.5% of claimants aged under 50 years were female, indicating potential gender disparities in diagnosis of early-onset cancer.
• 53% of the claims reviewed involved remote consultation claims, highlighting the increased importance of taking a comprehensive history taking where there is no physical examination.

According to the report, missed cancer diagnoses involving GPs are due to multiple factors, including lack of differential diagnoses, repeat reattendances, inadequate safety netting advice and failure to refer for investigations when indicated. The report concludes that “fragmentation within the system, coupled with the intricate nature of cancer pathways spanning multiple care providers and specialties, can lead to communication breakdowns and delays that ultimately affect patient outcomes.” 

NHS Resolution makes the following recommendations in the report to improve the rate of cancer diagnosis in primary care:

1. Develop system-wide quality assurance of primary care consultations to monitor and measure the effectiveness and improve unwarranted variation.
2. Configuring digital and telephony systems to detect and flag repeat attendances.
3. Agree clear risk indicators around repeat attendance, increased usage of urgent and emergency care services and deterioration despite treatment.
4. Optimise the availability, use and timeframes of diagnostic imaging support tools and specialty referrals and transparency of appointments and reporting times.
5. Explore Increasing routes to enter the cancer pathway.

Patient safety is a high priority for NHS England and GPs recently adopted Jess’s rule, which asks GPs to reconsider when they have been unable to substantiate a patient's diagnosis after three GP appointments. NHS England’s Advice and Guidance service also enables GPs to seek advice from specialists digitally before making a referral to help ensure patients are managed appropriately from the outset.

Whilst the report recognises the claims data represents a small number of cases, the themes provide an opportunity to learn, understand and begin to address the issues raised and to improve patients’ experiences and outcomes. GPs are under increasing pressure to treat patients more quickly and efficiently, which can in turn impact on the challenges they face in delivering care. However, this report will likely help to improve clinical decision-making in primary care and increase rates of early detection of cancer.