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Summary:  Prior to the emergence of the Covid-19 pandemic in England, most GP consultations occurred in-person in the surgery.  Even with this personal contact there is concern that some patients with low-risk, but not no-risk symptoms have repeated consultations before a condition is diagnosed, and it is important that these occur and are followed up appropriately. This is crucial when patients have symptoms that could lead to an important diagnosis such as cancer.

A stepped wedge trial of an electronic safety-netting Toolkit went live on 9th March 2020, with the first 10 practices (out of 60) turning the intervention on.  Almost immediately, the number of coronavirus cases increased, the country entered a state of medical emergency and within a week there was an almost ubiquitous shift from face to face consultations to email, telephone, or video consultations. 

The population is now accessing GPs in an entirely different way, and where possible staying away from medical services. This could have implications for the way patients present symptoms, the time to reach a diagnosis, and the mode of referral of patients to specialist services.

We are in a unique position to analyse the impact of Covid-19, and the alternative methods of GP consultation on the diagnosis of cancer.  We will compare the following outcomes during the 12 months prior to the pandemic with the pandemic period:  symptoms in those diagnosed with cancer; time to diagnosis; proportion of cancers diagnosed as emergencies; types of cancers; number of GP consultations during the primary care interval; mode of consultation and rates of patients referred by different referral pathways.

We will also undertake interviews with GPs to understand their perspectives regarding patient presentation, referral and diagnosis of cancer during the Covid-19 pandemic.

Aim: To analyse the impact of Covid-19 triggered changes in primary care consultations on the diagnosis of cancer.

Objectives: To determine whether the switching from primarily face to face consultations to remote consultations alters the presenting symptoms of cancer; primary care interval for cancer diagnosis, proportion of cancers detected after emergency presentation; site and stage of new cancers; total time to diagnosis; number of consultations during primary care interval; rates of patients completing direct access cancer investigations; and rates of patients referred by 2ww, urgent and routine routes. 

Methods:  The emergence of the novel coronavirus in the UK led to a pause being placed on a newly initiated stepped-wedge trial of an electronic safety netting Toolkit.  The first randomised step of 10 practices (out of 60) went live on 9th March 2020 but almost immediately the medical climate changed dramatically with Covid-19 increasing across the country. 

Despite the pause of the main trial, the currently active practices will keep the Toolkit turned on and will use it if appropriate, but without additional administrative burden of reporting several additional trial outcomes.

The outcome measures will be extracted from the electronic health record by the Structured Query Language (SQL) developer and provided in a pseudonymised form to the analysis team for the 12 months prior to March 2020 (baseline comparison period) and for the entire pandemic period, or until 31st October 2020, whichever is the latest.

A sample of 15 GPs from the participating practices will be interviewed to gain their perspectives on how the Covid-19 pandemic affected the presentation, referral and diagnosis of cancer. 

We will conduct a before and after Covid-19 analysis of outcomes, adjusted for the use of the Toolkit.

Impact:  This will generate important knowledge about optimising the use of remote consultations, particularly in regard to cancer diagnosis, to enhance public awareness, and implications for safety netting messages.

Timelines: data collection will continue until the declared end of the pandemic in England, or until end October 2020, whichever is the longest. An amendment to the current ethical approval will be sought, but this will not delay the study as data will be routinely collected and then extracted at the end of the period.