Interested in the effectiveness of the 2-Week Wait (2WW) referral system, we undertook an audit while doing our ear, nose, and throat (ENT) ST2 rotations for our general practice specialist training.
We were surprised by some of our findings. Of the 177 patients referred using the GP 2WW pathway during a 7-month period, 100% were meeting targets to be seen within 2 weeks, but only 6% (13/177) of these referrals were consequently diagnosed with head and neck cancer. In comparison to the incidence of cancer audited to be 23%1 for urology and 12.8%2 for breast 2-week wait referrals, ENT referrals appeared to have a much lower pick-up rate. In addition, of the 94% of the 2WW referrals which proved not to be cancer, we identified a sizable proportion that did not comply with the NICE 2WW referral guidelines.
While it is unavoidable that there will be a percentage of suspected cases that will have malignancy excluded by secondary care investigations, a large number of these 2WW ENT referrals may be given unnecessary priority over other general referrals thought to be less urgent, but which still affect a patient's quality of life.
Previously, other audits have shown a similar discrepancy with ENT referrals, and there have been multiple proposed reasons to explain this. For example, lack of knowledge of the 2WW referral criteria, or conversely, the poor predictive value of many of the 2WW referral criteria as symptoms suggestive of cancer. In addition, there has been suggestion of the inappropriate use of the 2WW referral system by primary care services. But perhaps there are significant contributing factors underlying all of these explanations — lack of clinical ENT experience, knowledge, and available diagnostics.
There is certainly some diagnostic difficulty with ENT malignancies relative to other types of cancer presenting in primary care. ENT symptoms of malignancy can be relatively non-specific and there are a lack of diagnostic aids, such as tumour markers and radiological investigations, making a malignancy difficult to exclude without an early referral. This difficulty only highlights the importance of clinical acumen in ENT assessment and diagnosis in primary care.
Despite ENT conditions making up to 25–50% of all GP consultations,3 with many chronic ENT problems managed solely in primary care, practical knowledge and experience in dealing with ENT problems by GPs may have scope for improvement.