NCPA - National Center for Policy Analysis

Some Wait Longer, Others Less

July 2, 2001

Since last year, Britain's National Health Service has been working to reduce its long waiting lists so that patients with suspected cancer would be seen by a specialist within two weeks of referral by their general practitioner. How is it working?

Not too well, say some physicians. Although there have been substantial reductions in delays for patients with suspicious symptoms as defined by NHS guidelines, several abstracts presented to the British Society of Gastroenterology suggest that the two-week standard is being met at the expense of a substantial increase in waiting time for routine referrals, while not necessarily identifying treatable cases of cancer.

  • Two separate audits undertaken in district general hospitals found that only one-third to one-half of patients with colorectal cancer were referred through the two-week arrangements, and one also identified a doubling in routine waiting time to 64 days.
  • A retrospective study of patients with colorectal cancer admitted with no referral guidelines to a single surgeon found that about 30 percent of cases would not have met the referral criteria.
  • The problem is that patients can meet the national guidelines and still be an "inappropriate," while patients who do not meet the guidelines can present with a high suspicion of cancer, appropriate for urgent evaluation.

The predictive value for colorectal cancer of persistent rectal bleeding and change in bowel habit, for example, is about 30 percent -- but significant numbers of patients with lower risk symptoms will nevertheless prove to have cancer and may now experience longer waiting times than before.

Paradoxically, those not immediately referred might harbor malignancy at an earlier stage, with better prospects of cure. Further research is needed to determine whether the initiative to shorten waiting lists reduces Britain's high cancer mortality rates -- or make matters worse.

Source: Roger Jones, Greg Rubin and Pali Hungin, "Is the two week rule for cancer referrals working? Not too well," Editorial, British Medical Journal, June 30, 2001.

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