Editor—Since the two week directive was introduced considerable debate has been surrounding certain aspects of it, especially how appropriate it is for general practitioners to determine urgency.1 It was our aim to examine how effective general practitioners' grading of urgency of referrals to our unit has been, comparing the referral grade with the eventual diagnosis.
The database of the breast unit at King's College Hospital retrospectively examined all general practitioners' referrals to the symptomatic breast clinic between April 1999 and December 2000. Altogether 3597 referrals were made, 665 were marked as urgent and 2932 as non-urgent. Sixty two urgent patients and 49 non-urgent patients were subsequently found to have breast cancer. The mean ages were 60.5 years in the non-urgent group and 59.9 years in the urgent group.
It is evident that the two week wait initiative is not ensuring that most patients with symptomatic cancer are seen within two weeks of referral. This is also seen in the British Association of Surgical Oncology's audit (23% of cases of cancer in the non-urgent group).2 The emphasis on seeing urgent cases within the time has been at the expense of the non-urgent cases. Waiting times in this group have increased to 12 weeks in some units.
What level of cancer cases in the non-urgent group would be considered acceptable? By grading patient referrals, we are creating a two tier structure, with patients in the non-urgent group waiting longer periods for diagnosis and treatment. For patients with cancers in this group the delay can be critical. The government's initiative should be applauded for ensuring a uniform standard, but its basis of using urgency of referral has meant unacceptable delays to some patients with breast cancer as well as delay with anxiety to those without. As no grading system is perfect, the only way of guaranteeing that all patients with breast cancer are seen within two weeks is by seeing all the referrals in this period.
This has become achievable at our unit, mostly through organisation and not resource allocation; this is dependent on flexibility and forward planning. The King's breast unit is part of a cancer collaborative that uses action research to introduce changes to improve effectiveness. This has been well summarised by an editorial by Smith and encapsulated by an aphorism originating from Mark Murray—“doing today's work today.”3
References
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- 2.Sauven P. Specialists, not GPs, may be best qualified to assess urgency. BMJ. 2001;323:864. [PubMed] [Google Scholar]
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