Non-specific symptom pathways: How are they working and where are they going?
27 April 2023
When it comes to diagnosing and treating non-specific symptoms (NSS) in cancer patients, a holistic approach is essential. However, the implementation of non-specific symptom pathways and national policies promoting holistic care can vary greatly among healthcare providers. In our workshop presented at the Cancer in Primary Care conference at Worcester College, Oxford, we discussed key challenges and future directions for research in providing comprehensive care to those with NSS.
First, we considered the way in which national cancer policies have emphasized the importance of assessing patients' symptoms holistically, and how services have implemented these policies in practice. We reported that limitations in imaging and diagnostic tools often lead to difficulties in delivering holistic care in NSS pathways. Additionally, different interpretations of what constitutes a holistic approach can create confusion and inconsistencies among healthcare providers. One major challenge highlighted by the study was the lack of policy direction and funding models for providing holistic care beyond cancer exclusion. This resulted in polarised views among study participants about the boundaries of holistic care and variations in its implementation among different healthcare providers.
Second, we considered the role of General Practitioners (GPs) and in particular, the ability to use ‘gut feeling’ when making a referral to a NSS pathway. We spoke about how GPs in Oxfordshire, who were among the first to have access to a NSS pathway in the UK, found using the Oxford SCAN Pathway. We described how the GPs who had responded to our request for feedback valued the SCAN Pathway as a way to get a thorough “top to toe” investigation of their patients, ruling out serious disease, and avoiding the multiple referrals that had previously been common for patients with non-specific symptoms. We then moved on to present findings from a study in which GPs raised what they thought were the important benefits of being able to use their gut feeling as a reason for referral when referring to the NSS Pathway - again, Oxfordshire GPs were among the first to be able to do this through the SCAN Pathway. These GPs told us that being able to use their gut feeling in this way was like having their expertise recognised, and helped them to communicate concerns when patients did not meet the referral criteria specified in clinical guidance. They also raised some concerns about the use of gut feeling though, specifically around whether it varied too much from GP to GP, or whether the reliability of gut feeling could deteriorate under the pressures and loss of continuity of care facing general practice.
Third, we considered the perspective from practitioners in NSS pathways, including improvement work needed to embed NSS pathways effectively. This included making changes to referral forms to align them with other cancer pathways, doing outreach communication work to explain the pathway to primary care practitioners. One specific aspect of this was the role of patient navigators, who guide the patient and other clinicians through the NSS pathway. We heard how initially, there was resistance to having a radiographer as a pathway navigator from clinical colleagues, and that it was difficult to access appropriate training. However, a radiographer had integral skills for the role such as exposure to a broad range of pathologies, networks across multiple hospital specialties and experience with a diverse patient demographic.
Finally, we considered how NSS pathways in the UK compared to those in Denmark, where similar pathways were implemented in 2012. They were also adopted in Norway and Sweden in 2015. Local variations in the implementation of the NSS pathways across Denmark have resulted in challenges in investigating and comparing diagnostic outcomes. Some areas have GPs conducting initial diagnostic assessments, while in others, diagnostic centres at the hospital level are responsible. This lack of consistency in implementing the pathway raises questions about the effectiveness of the system.
The final half hour of our workshop was given to audience discussion which raised a number of important questions. These questions included whether NSS pathways should be used as routes to rule out serious illness, rather than cancer specifically, due to the non-specific nature of the symptoms and that NSS pathways diagnose a large number of serious non-cancer diseases as well as cancer. The audience also suggested that NSS pathways could be sited in new community diagnostic hubs and that the role of primary care in NSS pathways could be increased (e.g. initial assessments being performed in primary care). Our conversations continued after the workshop and we would love to keep them going. If you have any thoughts about the implementation or future of NSS pathways please so get in touch.
Authors: Georgia Black (Queen Mary University of London), Claire Friedemann Smith (University of Oxford), Julie Ann Morland (Oxford University Hospitals) Christina Damhus (University of Copenhagen).