Havering North PCN in London conducted an audit to identify gaps in the cancer pathway during the patient journey to diagnosis. Dr Ameesh Patel, the PCN’s cancer lead, and GP trainee Dr Nikita Singh explain more.

The number of patients with cancer is increasing, with one in two individuals being diagnosed with a form of the illness. Regardless of the type of cancer, the quicker a patient is diagnosed, the better the outcome. However, NHS cancer services are under increasing pressure.

In England, the target is for 85% of cancer patients to start treatment within two months (62 days) of referral or screening, but the latest figures from Cancer Research UK indicate that this target is often missed. In March 2025, the rate was just 71.4% of people. Cancer Research UK says the 85% target has not been met since December 2015.

It is even more important, then, that diagnosis is as fast as possible - and general practice can play a role in this. However, an audit by a Havering PCN practice found that nearly a quarter of patients had avoidable delays in getting a diagnosis.

Aim

When North East London (NEL) Cancer Alliance presented an opportunity to conduct an audit, Havering North PCN agreed. We analysed data spanning six months (April-September) in 2024 to identify local gaps in the cancer pathway during the patient journey to diagnosis.

The rationale was that if we found causes of delays - systemic issues and common or avoidable incidents - we could take action to reduce their frequency and impact. This would lead to quicker diagnosis and thus earlier initiation of treatment. And, of course, it would ensure a straightforward pathway for patients, which would help reduce anxiety during a stressful time.

Part of the study involved looking at the average time between a patient being referred by the GP and being seen by the speciality team. The practice found that the average wait time was 15 days. The lowest wait was three days and the highest was 24 days. The Rapid Diagnostic Centre (RDC) at the local hospital – a one-stop clinic to investigate patients with potential malignancy of unknown source – had the lowest waiting times and the breast clinic had the highest.

Method

A search on EMIS was conducted to identify all patients who received a new diagnosis of cancer between 1 April and 30 September 2024. The search revealed 30 patients out of a patient population of 11,737.  

We wanted to find out the average number of visits a patient made to the GP before a cancer diagnosis was made to see if we could identify any gaps in knowledge or training, and we measured the length of time between referral by the GP and the appointment in secondary care.

An audit template was provided by the Clinical Effectiveness Group at Queen Mary University of London, as part of its remit to help primary care work smarter and reduce avoidable delays in diagnosis. The template enabled the auditor to get the relevant information from the notes, going through the patient journey to identify the cancer tumour site, stage of diagnosis, route to diagnosis and the cause of any delay. This helped us identify potential gaps in the cancer pathway.

Outcomes

Of the diagnoses assessed, 23% of patients had avoidable delays at different points in their journey. While that means that most diagnoses are made promptly, there is room for improvement.

We discovered that FIT tests had a varied return time by patients, and on occasion, were not being returned at all. This was the case in 6% of the data analysed, and added delays of up to three weeks.  

And we found that certain cancer diagnoses, such as pancreatic and stomach, took more GP appointments than other types of cancer. For example, pancreatic cancer took two to three appointments with multiple investigations, in contrast to breast and skin cancers, which required only one appointment.

There were delays when scans had vague reports - ‘potential malignancy’ or ‘suspicious lesions’. Where the malignancy speciality was clear, a direct referral was made. But there were cases where urgent MRI scans were requested prior to referral. In one case, it took 10 days for the scan to take place and two weeks to receive results and, in another case, the follow-up MRI occurred three weeks later.

Interestingly, prostate cancer was especially varied. Of the four diagnoses identified, two were made after a single appointment and two after three appointments. In those requiring multiple appointments, increasing PSA had not been noted on a background of either prostatectomy or being on alpha blockers/5 alpha reductase inhibitors (which can lead to misinterpretation of a falsely reduced PSA result).

Action

A PCN-wide change was implemented in April 2025 to code provision of FIT test – this is monitored by the PCN, so non-responders are flagged.

The finding that some cancers take more appointments than others before referral is likely due to their insidious and vague nature, often requiring multiple investigations and repeat appointments for results/further referrals. Nevertheless, some delays could be mitigated by targeted teaching on these cancers. The practice has introduced this to weekly meetings and has highlighted the need to check trends in PSA rather than simply filing a negative result.

The practice also plans to implement a warning pop-up for those who have historically had a prostatectomy to prevent this from happening to patients in the future. Additionally, they are suggesting that all clinicians write a message on the request form for the person checking the bloods – for example, PSA on background of finasteride treatment/ prostatectomy - as a final fail-safe.

The RDC could resolve any problem with inconclusive scans. Referral criterion to this is simply a strong suspicion of cancer, whether that’s clinical or a GP’s sixth sense, and investigations can be conducted faster than going through the testing process in primary care.

Future

The clear benefit of identifying gaps in the cancer pathway is to implement clear, repeatable actions to prevent them from occurring in future. It is about self-reflection and making changes in practice that will have real-world outcomes.

The audit template could also be used to identify health inequalities in diagnosis. Although we did not analyse this data, the template captures ethnicity, background of dementia/learning difficulties, advocacy needs and whether the patient is housebound.