Investigating the impact of changes in the NHS in response to the COVID-19 crisis on cancer diagnosis in the South West of England

Introduction

The COVID-19 crisis has resulted in many important and immediate changes in health policy in the UK National Health Service (NHS), many of which impact upon the process of investigating and diagnosing cancer in primary and secondary care. As of March 2020, such changes across the healthcare system include fewer consultations in primary care, as the public are urged to minimise use of healthcare services, general practices moving to telephone triage in preference to face-to-face consultations, and secondary care-based investigations suspended or significantly reduced as clinicians are diverted towards the efforts to deal with the COVID-19 crisis. In particular, endoscopies and imaging have been massively curtailed. These changes will have an unprecedented impact on cancer diagnosis, a process informed by NICE guidance. It is highly likely that the suspension of investigative services will result in delayed diagnoses, some of which will result in stage shift and poorer survival, although this will vary by cancer site.

In this study, we aim to estimate the impact of the changes in the healthcare system made in response to the COVID-19 crisis on cancer diagnosis in the South West of England. There are three main benefits from this: firstly, to document some of the ‘negative’ impacts of the massive NHS realignment towards COVID-19 care; secondly to help guide policy decisions on catching up with usual care in the wake of the COVID-19 crisis; and thirdly to use this ‘natural experiment’ to reveal where delays in cancer diagnosis have the greatest impact on cancer outcomes. With this knowledge, future interventions to expedite cancer diagnosis can target cancer sites where earlier diagnosis will make the most important difference to patient outcomes.

We postulate that there has been a decrease in primary healthcare use from March 8th, 2020, accompanied by a change in delivery of primary care, reduced two-week-wait (2WW) referrals, reduced (or deferred) investigation in those 2WW referrals, a higher proportion of cancers presenting as an emergency (with some additional mortality), a worsening of stage at diagnosis for the cancer sites most affected, and worsened survival from cancer. These effects are across all cancer sites (though the primary care effects may be so) but particularly affect cancer sites requiring CT/MRI imaging, or endoscopy for primary diagnosis.

Aims & objectives

To determine the impact of changes in NHS policy in response to the COVID-19 crisis on cancer diagnostic activity and outcomes in the South West of England. There are two main objectives:

1) to examine if new cancer diagnoses fall pro rata with the fall in 2WW referrals and cancer investigations (if they don’t, this is evidence that GP input is being partially effective in selecting those most in need)

2) to use the natural experiment of a diagnostic delay to learn the true impact of cancer diagnostic delay – and by inference, the benefits from accelerating cancer diagnosis.

Methodology

This clinical audit will collate routinely collected electronic healthcare data on investigations for suspected cancer, and cancer diagnoses, during 2020. We will use our existing network in the South West to collect up-to-date observational data, directly from secondary care, to track cancer investigation and diagnosis before and during the COVID-19 crisis. This study is based in secondary care settings covered by the Peninsula Cancer Alliance and the Somerset, Wiltshire, Avon, and Gloucester (SWAG) Cancer Alliance. This geographical area includes a patient population of approximately 4 million, 10 CCGs, and 14 Trusts. In this region, we estimate there to be 23,000 new cancers annually, of whom approximately half would have been diagnosed during the COVID-19 crisis period.

Next steps

We are currently collecting data for this study and hope that results will be available later in 2020.