A Rapid Access Diagnostic Clinic at Guy’s and St Thomas’ NHS Foundation Trust for patients with vague but worrying symptoms shows promising early results.
The clinic was launched at Guy’s Hospital in December 2016. Patients are referred after presenting to their GP or A&E with vague but worrying ‘red flag’ symptoms.
The patient journey includes an initial appointment with a consultant and advanced nurse practitioner, investigative tests (conducted on the same day or within seven days) and a follow-up appointment with three potential pathways: two-week-wait cancer referral; referral for benign but serious condition; or discharge to primary care with appropriate advice.
Of the 570 patients seen during the first 16 months, 8.6% were diagnosed with cancer, and 25% of these were stage 1 or 2.
Financed through local CCGs and some transformation funding it was decided to pilot an RADC at Guy’s Hospital. The aim was to speed up cancer diagnosis, as well as finding more cancers at grade one and two, in patients presenting with vague symptoms.
Initially piloted with two CCGs, Lambeth and Southwark, its success saw it rolled out across all six CCGs in south London in April 2018.
The service model
GSTT RADC provides a diagnostic service to patients who have presented to their GP or at the Accident and Emergency Department with vague but worrying ‘red flag’ symptoms. It follows a model of fast patient triage; coordinated access to diagnostic tests; second follow up appointment or telephone consultation resulting in rapid specialist referral or patient discharge.
Within seven days of a referral being made, a patient will attend an initial 45 minute appointment with Dr Luigi DeMichele, the clinic consultant and Geraint Jones, advanced nurse practitioner. A detailed medical history will be taken, appropriate investigations completed and the patient will be screened for any unmet fraility, mental health and social needs.
If further investigations such as a CT scan or endoscopy are needed, the patient will be given a slot on the day or a date and time to return within seven days.
At their second appointment with Dr DeMichele and Geraint, the patient will be involved in a discussion about the results of their investigations. At this point there are three potential pathways: 2 week wait cancer referral, referral for benign but serious condition or discharge to primary care with appropriate advice and signposting to any relevant teams/ agencies (for example, the community mental health team).
A patient in which a serious condition has been diagnosed or is suspected, will be rapidly referred to another specialist for appropriate care and treatment. In the case of a patient with a suspicion of cancer, the internal pathways in place between the RADC team and specialities ensures that the patient is seen by the appropriate specialists within fourteen days.
It is too early to say that the RADC has definitely improved patient outcomes but the early findings are promising:
- 570 patients completed their RADC journey during its first 16 months of operation
- 300 (58.82%) patients diagnosed with a serious benign condition including cirrhosis of the liver, multiple sclerosis, tuberculosis, heart failure, emphysema and Crohn’s disease
- 44 (8.6% of all patients) diagnosed with cancer;
- 11 of these 44 (25%) cancers were diagnosed at grade 1 or 2
- 93% of patients rated their care as very good.
The patient’s experience
When Yvonne Allen suddenly started experiencing pain in her lower back and side, she booked an appointment with her GP. The 61-year-old had vague symptoms and painkillers were not helping so the doctor referred her to the rapid access diagnostic clinic at Guy’s Hospital.
Yvonne, from Southwark, says: “The clinic was fantastic and, over the next few weeks, I had a range of tests including an MRI scan, endoscopy and blood tests.
Scans revealed that Yvonne had a lump in her lower intestine so she was referred to the gastrointestinal unit and was diagnosed with bowel cancer. She had an operation to remove the tumour and is continuing to take medication.
Yvonne says: “It wasn’t the outcome I expected but I’m glad it was discovered and treated so quickly.
“This type of cancer is like a silent killer – there were no obvious symptoms so it wasn’t easy to detect. I believe in knowing your body and, if something doesn’t feel right and is out of the ordinary for you, get it checked by a doctor.”
- Patients with cancer and other serious conditions are diagnosed quickly, referred for appropriate treatment and start treatment much more quickly
- Patients who have traditionally struggled to get a diagnosis, now have a diagnosis for their condition
- Patients are being diagnosed in a clinic where appropriate advice and support can be given rather than at A&E
- Patients feel listened to and that their symptoms are being taken seriously, leading to high levels of patient satisfaction
- Many patients are quickly reassured that they do not have cancer, as well as receiving a prompt referral to the appropriate specialist
- Very high patient satisfaction levels [93%  rated their care as very good].
The team at the RADC have seen:
- Patients quickly diagnosed and appropriately referred for treatment
- Increased uptake in GP referrals
- Early stage cancers diagnosed in patients who ordinarily might be missed due to vague symptoms
- Over time, the team expect to see a reduction in A&E presentations and repeated presentations to their GP of patients with certain cancers such as GI cancers.
Dr Anthony Cunliffe, GP at Stockwell Group Practice said:
“We are often faced with patients who have vague and concerning symptoms, but who don’t have an obvious diagnosis, or it’s unclear where they need to be referred to.
“In these situations it can be difficult to ensure that the patient is investigated in the quickest and most appropriate way. The Rapid Access and Diagnostic Clinic provides an opportunity for these patients to be seen and investigated quickly, ensuring any sinister diagnosis is reached as quickly as possible, or gain reassurance that nothing serious is going on.”
Geraint Jones, Advanced Nurse Practitioner at the RADC, said:
We can turn diagnostic tests around quickly before referring patients to the specialists that they need to see. We have developed robust internal pathways to ensure the patients are reviewed by the relevant specialities in an appropriate and timely manner.
“I especially appreciate the time to screen the mental health and social needs of our patients, so that we can plan for their mental health and support needs alongside their physical needs.. Many patients have depression, anxiety or feel isolated and due to the clinic timeslots we are able to begin to address these issues.
“Dr DeMichele, has a background in internal medicine as well as geriatrics which has really helped in the diagnostic process.”
- Faster diagnosis requires effective internal pathways – ensure these are in place and you have full commissioner buy-in along the pathways before you start
- Effective communication is needed – ensure that the hospital teams who will be involved in the RDAC pathway are fully aware of the project, understand it and appreciate the importance of its goals
- Rapid access to diagnostics is essential – ensure that access to the different diagnostic tests including CT scans, endoscopy is adequately ring-fenced
- Avoid clogging the system – ensure that internal pathways ensure quick access to specialists and do not slow diagnostics from other specialities.
- Hold regular multidisciplinary meetings with relevant departments such as radiology and geriatrics
- Plan for discharge right at the start – ensure effective links with community mental health services/ social services and be familiar with community based teams that can assist when required.