Why we need to Think GI Cancer

The Primary Care Society for Gastroenterology. The clue’s in the name: it’s about primary care and gastroenterology.

At the moment primary care in the UK is on its knees. Workload up, profits down, drowning in targets and paperwork. This is more than the usual ritualistic shroud waving which is a necessary part of negotiation in the health service.

We’ve been here before in the years immediately before the reforms that brought in fundholding and then the new GP contract (saying this is worse than those times doesn’t help and reminds me of arguments about whether renal colic is more painful than childbirth). It’s really bad now, and it feels really bad: enough said.

Lack of recruitment is a worry. In my role as coach with the Thames Valley Professional Support service, I get to meet lots of young doctors and not many are finding general practice an attractive career option. Instead they are either embarking on a hospital specialist training, or taking an ‘FY3’ year – which is just code for going to Australia then doing locums. Or making plans to leave medicine altogether.

One factor in the mix that really shouldn’t be there is the poor image of general practice that young trainees are still being given by hospital doctors. Isn’t it time we worked together?

Having a specialist skill and a toehold in secondary care makes primary care a more interesting place. We know of one doctor who has recently successfully trained as an endoscopist while doing her GP training and have had enquiries from others. We will be encouraging, signposting and lobbying for this path to be made a bit easier to the benefit of both secondary care, by increasing capacity; and primary care, by increasing recruitment and retention. Isn’t it time we all worked together?

If UK general practice is in a mess then so are some parts of UK gastroenterology. Of particular concern must be the poor outcome figures for gastroenterological cancers. We come near the bottom of the European league tables.

We can blame patients for presenting late – the British stiff upper lip – but this might be an excuse for making accessing primary care difficult and inconvenient. And access is about being psychologically and emotionally accessible too. To actively listening to a nervous patient tell their story despite doctor fatigue, both physical and emotional.

The PCSG is launching a campaign to try to improve outcomes for gastroenterological cancers, Think GI Cancer. Clearly there are many strands to the problem but joined up services and working between primary and secondary care would seem fairly fundamental.

We were always taught to use time as a tool and in fact this is still mentioned in the trainees e-portfolios as a good thing. The problem is if you suspect, even slightly, that a patient might have cancer but wait to see if you are right, you might have waited too long.

Clearly not all patients need referral but we should be doing better than ‘seeing how this one pans out’. Interesting then that a recommendation in the guidelines to help sort who needs to be referred has caused a furore in the gastroenterological community.

The recommendation, as I understand it, is that faecal occult blood testing should be used in those cases that do not justify an immediate referral but are going to get a routine one. A positive FOB would ‘upgrade’ the referral.

The gastroenterologist seem to saying this is a discredited test that gives false positives and false negatives; the academic GPs proposing it counter with, “What about the true positives?” It’s a debate that we will be carrying in the forthcoming issue of the Digest.

In the meantime … shouldn’t we just work together?