Less haste more speed: factors that prolong the interval from presentation to diagnosis in some cancers

In the UK, the GP is the gatekeeper to specialist services in addition to many other roles. Recently, the GP is also expected to select cases that warrant 'urgent' as opposed to 'routine' specialist investigation. Failure to refer on the appropriate timetable may have implications for timely diagnosis.

Our aim was to explore the circumstances in which the diagnosis of cancer is delayed with reference to the primary care records and by a structured investigation of clinical records in one practice.

The study was set in an urban group practice serving a mixed population of deprived and affluent communities. List size was 10 440 patients, with five whole time equivalent partners and three practice nurses. The appointment system was fully computerized and there were no personal lists. Records for all cases with specified common cancers diagnosed since 1990 and still registered in the practice were reviewed. The interval from presentation to referral, referral to diagnosis and presentation to diagnosis was compared for a series of factors including 'urgent' referral. The clinical team currently working in the practice conducted a structured review of the case records for the most delayed cases.

Fifty-four cases were listed in the practice. A series of factors were identified as having a bearing on delayed diagnosis, including a reticence on the part of patients to seek to expedite specialist appointments, failures of communication, and patients presenting multiple problems in short general practice consultations. The action plan agreed by the clinical team includes improving the quality of communication with secondary care, follow-up of patients who have been referred for radiological or ultrasound investigation and reviewing patients who fail to attend specialist clinics.

The data imply that delays sometimes result from avoidable errors before and after referral and especially by the patient entering secondary care on the wrong pathway. Improving the patients' experience in health care requires the provider to take a global view of the service. Primary care is not merely a filter but influences and is influenced by policies in other parts of the health care system.