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GP advice service linked to missed cancer diagnoses, inquiry finds

An investigation has found that a system designed for GPs to seek specialist advice before hospital referrals has contributed to missed or delayed cancer diagnoses.

  • The Health Services Safety Investigations Body (HSSIB) identified patient risks linked to the implementation of advice and guidance (A+G) services across England.
  • The HSSIB report found evidence that A+G contributed to patient harm, including delayed or missed diagnoses, where it was poorly implemented or monitored.
  • NHS England and the Department of Health and Social Care have been recommended to rapidly evaluate A+G services.

Cancer diagnoses have been missed or delayed due to a system intended for GPs to seek specialist advice before referring patients to hospital, an investigation has revealed.

The Health Services Safety Investigations Body (HSSIB) identified patient risks associated with how advice and guidance (A+G) services have been implemented across England. While A+G was introduced to reduce unnecessary hospital visits and waiting times, the investigation found evidence of harm where implementation was inadequate.

The report stated that harm had arisen from delayed or missed diagnoses, and delays to care and treatment. It noted that A+G services were being used in some pathways where general practice had requested specialist assessment for suspected cancer, contributing to diagnosis delays.

Gaps in system implementation were also identified, including local pathways requiring A+G instead of direct referrals, or referrals being rejected despite GP concerns. The HSSIB has recommended that NHS England and the Department of Health and Social Care rapidly evaluate A+G services to address resource and capacity gaps, training needs, and weaknesses in reporting patient safety incidents.

NHS England acknowledged that A+G has positively influenced patient care but stated that more needs to be done for it to work effectively. They are providing guidance and tools to GPs and hospitals and have commissioned an evaluation of its impact, set for publication this year.

Why this matters: The findings highlight potential patient safety risks within a system designed to improve patient care and reduce waiting times.

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