Opinion: Let pharmacists make two-week cancer referrals
Community pharmacy should be allowed to make clinically appropriate two-week cancer referrals. This would help relieve pressure on GPs and provide a faster pathway to diagnosis, particularly in areas where health inequalities are more persistent, says pharmacist Ade Williams
Health secretary Sajid Javid has declared a ‘‘war on cancer’’. Why? Because, at the end of 2021, over 6 million people in England were waiting for a cancer diagnosis and treatment.
The health secretary confirmed he is working on a new vision to radically improve the outcome for cancer patients with prevention and earlier diagnosis as its cornerstone.
His shadow, Wes Streeting MP, who completed treatment for kidney cancer less than a year ago, is committed to making sure any war on cancer is waged successfully. So where does community pharmacy fit into the war?
Sadly, there is a moment that gets played out too many times across the country, each one etched in our hearts. A familiar face walks into the pharmacy; we notice something in their eyes, their demeanour, a slumped shoulder.
The journey into the consultation room is solemn. Often, with the most dignified delivery, the news is shared. That one medical diagnosis – the dreaded C word – yes, cancer.
The same emotions play out as a prescription arrives for palliative medication for a patient who was so full of life just a few weeks or months earlier. Even worse, is the shock of medicines returned at the end of life, that late diagnosis leading to rapid deterioration.
The coronavirus pandemic has impacted usual cancer referral pathways – and that, together with lower uptake or availability of routine screening appointments, is the reason why 6 million people are waiting for a cancer diagnosis and treatment – a backlog that is expected to reach almost 13 million people in the coming years.
The scale of the crisis and recommendations on how to restore services and catch up can be found in multiple reports, including one by Macmillan, which found that there were 50,000 potentially missed cancer diagnoses in the first year of the pandemic.
The policy paper, ‘Catch up with cancer – the way forward’, estimates that 40,000 fewer people than normal started cancer treatment in November 2020, while referrals of suspected cancer fell by 350,000 in March-August 2020 compared to 2019.
There are many reasons for missed presentations and diagnoses beyond the changes in primary care and referral pathways that occurred in spring 2020. Many people delayed presenting symptoms due to psychological barriers associated with Covid-19.
News reports about the number of Covid patients in hospital led to understandable concerns about returning to clinical settings. As a result, many people are still holding off on planned investigative appointments.
When general practice moved to new ways of working, the bulk of face-to-face consultations in the country fell on the shoulders of community pharmacy.
For the first time, the public and the health service saw the full depth of our expertise and innovation.
We delivered face-to-face care, Covid-19 vaccinations, minor injury services and helped to diagnose serious conditions such as cancer, over the pandemic.
With these newly distributed primary care roles, the gateway of the NHS may have buckled but it did not break.
Data from a PSNC audit provides a measure of the reliance that the public has had on pharmacies through the pandemic, and the headline figures are truly staggering. On average, pharmacies undertake:
- 170,000 consultations per day
- 1,125,540 consultations per week (of which just under 130,000 are informal referrals from general practice and NHS 111)
- More than 58 million consultations per year.
Figures also show that 38 million people visit pharmacies for symptom advice each year. In 12.4 per cent of consultations regarding concerning symptoms, patients are referred to another health professional such as from their local GP practice.
Such data does more than merely reveal the pressures on, and the benefit of, community pharmacy. It also shows areas where we need policy to change to effectively empower community pharmacies to address the backlog and promote early diagnosis.
We need better-integrated measures to effectively capture both the formal and informal referrals. We also need to ensure that pharmacy is funded appropriately to manage them and has the tools to provide safe patient care.
A recent study by the University of Bristol in my local area, which was funded by the National Institute for Health Research, found a drop in cancer presentations to GPs.
Pharmacies have been there to help identify these patients so they should be allowed to make clinically appropriate two-week cancer referrals – both to relieve pressure on GPs and provide a faster pathway to diagnosis, particularly in areas where health inequalities are more persistent.
Formal pathways needed
From my work and discussions with colleagues, I know that undiagnosed cancer patients are presenting in community pharmacies. I know non-specific cancer symptoms and use informal, locally agreed referral pathways into general practice where possible.
Should our ambition not be to embed into every pharmacy evidence-based formal referral pathways? What are the barriers, and can we afford to delay removing them?
We also need the integration of data planned between GPs and hospitals to extend to pharmacy. This will allow for more effective communication in diagnostics, treatment and the reporting of side-effects.
It will also mean that pharmacists are armed with the tools to make the most appropriate referral decisions.
During the pandemic, cancer never stopped. Early diagnosis is universally accepted as necessary for best treatment outcomes.
Those conversations that used to fill us with much dread have morphed into statistics and ever more frightening cancer headlines.
We must continue to increase the speed, equity and ease of cancer diagnosis alongside providing much-needed reassurance to the public.
Sadly, as I comb through policy and research papers, it is evident many people still need to understand and discover the importance of community pharmacy in unlocking early cancer diagnosis. This lack of acknowledgement is a sinking weight.
The only way to thank community pharmacy teams for always making time to provide evidence-based care, following up referred patients and providing much-needed reassurance, is to empower them.
We must all now tackle the barriers and build the bridges needed to create the workable, sustainable change required to improve early diagnosis and make the most of the unique strengths of community pharmacy.
Ade Williams is director and superintendent pharmacist at Bedminster Pharmacy in Bristol. Are you seeing more cases of suspected cancer? Tell us at firstname.lastname@example.org