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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 August 25; 335(7616): 361.
PMCID: PMC1952477
Two Week Rule

Breast cancer experience has wider implications

S Michael Crawford, consultant medical oncologist

The implications of the fast track referral policy for suspected breast cancer raise issues for the NHS that go beyond this disease.1 2 The existence of two queues for investigation defies the sensible observation that to manage multiple queues for a particular service is inefficient.3

Potter et al list the criteria by which general practitioners (GPs) are expected to identify patients for urgent attention.1 Their paper shows that the sensitivity and specificity of this discriminant in real clinical practice are low. We do not know how many patients were inappropriately reassured by their GPs before being found to qualify for referral, but experience suggests that there will have been some. All this comes about because the capacity for specialist assessment of women with breast symptoms is inadequate; the real comparison is with those health systems that allow patients direct access to specialists whose workload is therefore unfiltered but which attain timely diagnoses.

When resources are diverted to ensuring that fast track patients are seen within the target time at the expense of standard patients, including those with cancer, an illusion of success by the system is created. This is a manifestation of Goodhart's law, which states that once a measure, such as the time to an urgent consultation, is made a target for the purpose of conducting policy it ceases to be a meaningful measure.4

The wider relevance to the NHS is that as the trend is towards many services being provided by very specialised teams in a small number of locations, access to them will be in the hands of gatekeepers who lack specialist expertise. It is important that the specificity and sensitivity of the discriminants they use are properly assessed. If the sensitivity is such that the number of patients denied access to a service is kept at negligible levels the specificity is likely to be low. This will demand that the specialised service has the capacity to accept patients who do not need the intervention offered. The numbers may well be such that rather than a regionally centralised facility, these services will more effectively be provided in dispersed locations.


Competing interests: SMC practises as a tertiary referral specialist in a district general hospital.


1. Potter S, Govindarajulu S, Shere M, Braddon F, Curran G, Greenwood R, et al. Referral patterns, cancer diagnoses, and waiting times after introduction of two week wait rule for breast cancer: prospective cohort study. BMJ 2007;335:288-90. (11 August.) [PMC free article] [PubMed]
2. Jiwa M, Saunders C. Fast track referral for cancer. BMJ 2007;335:267-8. (11 August.) [PMC free article] [PubMed]
3. NHS Modernisation Agency. 10 High Impact Changes for service improvement and delivery: a guide for NHS leaders London, 2004
4. Goodhart CAE. Monetary relationships: a view from Threadneedle Street. In: Papers in Monetary Economics Volume I Sydney: Reserve Bank of Australia, 1975

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