Final Report of the Evaluation of Rapid Cancer Diagnostic Services

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Maguire, Roma and van der Meer, Robert and Egan, Kieren and Thompson, Nathan and Connaghan, John (2024) Final Report of the Evaluation of Rapid Cancer Diagnostic Services. University of Strathclyde, Glasgow.

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Abstract

The Centre for Sustainable Delivery (CfSD) commissioned the University of Strathclyde to conduct an evaluation of Scotland’s Rapid Cancer Diagnostic Services (RCDS). The establishment of RCDS person-centred fast-track diagnostic pathways aims to provide primary care professionals with a new route to refer patients with non-specific symptoms, such as unexplained weight loss, pain or fatigue that may be suspicious of cancer. The implementation of the RCDS principle is timely, given that the Covid-19 pandemic has demonstrated the need for local delivery of diagnostics, where feasible, and a reduction of footfall within secondary care. The first three RCDS pathways were established in NHS Ayrshire & Arran (hereafter NHS A&A), NHS Dumfries & Galloway (hereafter NHS D&G) and NHS Fife, respectively, in spring 2021. A further two RCDS pathways were established in April 2023 in NHS Lanarkshire and NHS Borders. This evaluation report explores three key objectives, to: (i) determine the impact of the three early adopter pathways (alongside early data from two additional sites), while providing recommendations for the wider delivery of the RCDS model across NHS Scotland; (ii) identify the optimal components of the RCDS model in NHS Scotland; and (iii) report on findings and provide recommendations to inform evidence-based decision making. Answers to these questions are underpinned by both quantitative and qualitative data collection and analysis. Data sources used to support findings include a nationally agreed minimum dataset collected by all five of the NHS Boards alongside patient and primary care surveys, respectively, developed by CfSD and administered by the five Boards. The report also discusses findings from qualitative interviews conducted by the University of Strathclyde in both 2022 and 2023 with RCDS patients and a range of healthcare professionals. Evaluation findings and recommendations demonstrate the rapid speed at which cancer diagnoses are made across all 5 NHS Boards: the overall mean time to outcome across the five of the pathways is 16.3 days, well within the 21-day target set by the RCDSs. A number of other pertinent and favourable findings were also demonstrated including that the RCDS demonstrated both an enhanced patient experience and was satisfactory in terms of overall equity of access. There is early evidence suggesting that the RCDS is reducing pressures on primary care services and also early anecdotal evidence of improved clinical outcomes for patients. Presentation of ‘unexpected lab results,’ ‘GP gut feeling’ and ‘nausea/appetite loss’ on referral and cognitive impairment as a co-morbidity were suggestive of a positive correlation with cancer incidence (see Table 2). CT scanning plays a prominent role in the diagnostic process (see Figure 16). The health economic evaluation of the first RCDS pathways (NHS A&A, NHS D&G, NHS Fife) consisted of a detailed analysis of the average per-patient cost of managing and running each pathway, in addition to the average time from referral to RCDS outcome in each pathway. Patients were assumed to derive a utility gain from a faster time to RCDS outcome, which implies a reduced period of uncertainty and potential anxiety. Overall, this evaluation found RCDS pathways to be cost-effective when compared to general surgery pathways for patients with vague and complex symptoms: any cost differentials tended to be outweighed by patient utility gains from a faster time to diagnosis. This finding is in line with the main conclusion of the study by Sewell et al. (2020) on the cost effectiveness of the pilot Rapid Diagnosis Centre (RDC) in Swansea Bay University Health Board (SBUHB) in Wales. On the other hand, a direct comparison of costs and timings of RCDS with a GP Direct Access pathway is currently problematic. Any comparison of RCDS with a pathway in which the organisation and management of the diagnostic work-up falls on the GP rather than a wider team of specialist RCDS staff, would have to rely on several key assumptions that need to be underpinned by further in-depth research. First, the frequency of any tests (including CT scans) requested for patients may, or may not, be similar between the pathways: a possible assumption is that GPs may request more CT scans than RCDS teams. Second, the quality of diagnostic decision making may, or may not, differ significantly between the pathways: a possible assumption is that, in the absence of a specialist RCDS team, a GP Direct Access pathway may lead to unwarranted delays for some hard-to-diagnose patients. A solution that is both clinically effective and cost effective could involve running RCDS pathways and GP Direct Access pathways side-by-side (in addition to the site-specific pathways) provided that primary care physicians are guided to make referral choices that are optimal for each pathway. Optimal components of the RCDS model in NHS Scotland include: (i) Vetting and triage by the RCDS team, (ii) Personalised and single point of contact provided for each patient by a designated RCDS team member from the point of referral, (iii) Coordinated testing, including close liaison with the Radiology department, (iv) Diagnostic decision making by the RCDS team and MDT and (v) Appropriate onward referrals by the RCDS team for patients with an initial diagnosis or suspicion of cancer to a specialist cancer pathway. While there is good evidence to suggest that the RCDS pathways are effectively embedded in each of the 5 Health Boards, there is scope for further development. These include the implementation of primary care decision support tools to help healthcare professionals recognise potential signs and symptoms of cancer, and the use of longer-term follow-up procedures for RCDS patients not diagnosed with cancer or a specific non-cancer condition. While there are many strengths of this work included in the wide range of quantitative and qualitative data sources, it is also important to recognise limitations. This includes our evaluation lacking systemic (e.g., minimum dataset) information regarding decision making at the primary care level alongside information regarding longer term outcomes and impacts on patients (both cancer and non-cancer diagnosis). It should also be noted that whilst our qualitative interviews with patients and professionals included all 5 health boards, some boards had greater representation than others. Our evaluation raises the need for continuous learning of these new pathways and approaches (should pilot approaches be delivered long term) including through the evaluation of longitudinal clinical follow up at the individual patient level.

ORCID iDs

Maguire, Roma ORCID logoORCID: https://orcid.org/0000-0001-7935-3447, van der Meer, Robert ORCID logoORCID: https://orcid.org/0000-0002-9442-1628, Egan, Kieren ORCID logoORCID: https://orcid.org/0000-0002-1639-4281, Thompson, Nathan and Connaghan, John ORCID logoORCID: https://orcid.org/0000-0001-5558-7986;
CORE (COnnecting REpositories)