Jeremy Hunt’s bizarre ideas show that he doesn’t understand general practice

Without commenting on Mr Hunt's motivation or intentions, this does raise a common issue. Almost everyone, seeks to have transparency in the behaviour of others, and for other people's successes and failures to be 'auditable'. But everyone also seems to find it much easier to see behavioural flaws in others (other people or other professions) than in themself: it is also easier to see the problems you are faced with personally, or as a profession [which can lead to a dubious belief that 'my position in all of this is the trickiest and most challenging'}.

When you suggest that the machinations of politicians should be subject to 'transparency', and that their own 'success' should be 'auditable', I suspect they will come up 'but different rules must apply to us !'.

So I can of course see the consequences of this idea from Hunt - however, I can't see that GPs should be treated as in some way 'special'.

The basic problem, is the difficulty of 'auditing' what almost everyone can see, when faced with it, is good or bad behaviour - the problem of trying to go from 'you know it when you see it' to 'producing a numerical metric of quality'. Combined with the 'slicing the cake' factor, then even if you merely measure a simple 'outcome' as the audit, you still haven't cracked it because of the robbing Peter to pay Paul consequences.

This is perplexing enough as a 'theoretical' problem - if you throw in some politics as well ......

Dr McCartney is right in her criticism of the basic lack of understanding of medical care, let alone general practice, by Mr Hunt. She rightly points out that scrutiny has its place and auditing how new diagnoses are made can be useful; and she states transparency should be the norm.

This issue first arose in December 2013 when the data was released by NHS England and the story was taken up by the press including BBC Today programme . The report stated that 59% practices have more than 50% of their cancer diagnoses are delayed. The following debate did not question the provenance of the data.

I checked my own practices Primary Care Webtool data and it suggested that we referred 62% of our cancer referral promptly. This seemed unlikely and so I undertook an audit to see how other data sources (the EMIS record) compared. The practice traps all new significant diagnoses including cancer diagnoses and codes them on EMIS. The Webtool data was for one year but which year was not clear.

A search for all new diagnoses of cancer identified 61 codes. Of these 18 were duplicate codes on patients previously diagnosed. This left an audit population of 43 patients; one patient was excluded as their cancer diagnosis was subsequently reviewed and re-diagnosed. I used Cancer Research UK statistics (39 new cases in a practice our size) to check that all new cancer diagnoses were detected by this method (42 new cases).

A detailed review was then taken to determine the diagnostic path of each of the 42 cases: Twenty-nine patients were referred under the two-two referral process(69%), and these seems to correlate with the 62% quoted by the NHS England data (allowing for a different years data); however, 4 patients were referred direct from imaging (9.5%) after urgent referral for imaging; and 5 patients were referred direct from national screening (12%) programmes.

Of the four cases remaining: 2 were diagnosed by secondary care by serendipity when completely unrelated investigation detected a cancer; one patient was diagnosed after a written discussion with a consultant suggested the non TWR route was more appropriate; finally, one patient was admitted to 2 separate hospitals with acute pneumonia and the lung cancer was diagnosed at interval scan.
By my reckoning 40 patients were either referred early, or before any symptoms, of cancer were evident. This suggests that the correct rate is 95% and not the 62% quoted by NHS England.

I believe that primary care is happy for scrutiny; but let it be transparent about what the data collected actually means.

Einstein famously quoted that “information is not knowledge. The only source of knowledge is experience.”

REFERENCES:
1. BBC Today Programme Saturday 7 December 2013 (07.33 and later accessed on I-player) news and subsequent interview.
2. Cancer Research UK. UK UK Total of cancer incidence. http://www.cancerresearchuk.org/cancer-info/cancerstats/incidence/all-ca... accessed 10th Dec 2013.

I was taught by my trainers that identifying the earliest signs and symptoms of internal malignancy was a vital and integral part of a GPs job. To separate the signal from the noise is always difficult at best and some doctors seem to develop this facility as an art . This doesn't always help patients as specialists may discount referrals based on nous rather than science. I agree with Jeremy Hunt that some doctors are consistently better at this than others.

The best way of levelling up in this regard is not to use punitive measures as Margaret McCartney says. Developing systems to help improve cancer diagnosis can, with thought, will and resources, be developed to assist GPs in collaboration with relevant specialist colleagues. Formal auditing of these referrals will improve performance. No one is perfect but not to learn from mistakes is unprofessional and unforgivable. Doctors are best professionally motivated by the esteem of patients and colleagues and feelings of self worth. It is no longer acceptable to teach medical students by public humiliation. The same must apply to medical graduates.