Introduction

General practice teams are currently able to directly access tests for patients in several imaging modalities, including ultrasound, X-ray, computerised tomography (CT) and magnetic resonance imaging (MRI). However, variability in testing capacity and access to a convenient mechanism to refer for an imaging test directly has limited GPs’ use of direct referral in some areas of the country.

NHS England is working to open community diagnostic centres (CDCs) seven days a week so that they provide up to 9 million tests a year by the end of 2024/25. By combining this increase in diagnostic capacity, with existing diagnostic resources, we will ensure GPs have increased and swifter access to more diagnostic imaging tests and patients will be receive diagnoses sooner.

We recognise that systems are facing workforce challenges. NHS England is supporting systems to mitigate those challenges as far as possible by creating opportunities to optimise the existing workforce now while also growing the workforce over time. We are providing funding to ensure that each CDC has the right workforce in place and supporting systems to make the most of CDCs and diagnostic networks as opportunities for upskilling and cross-boundary working. We are also working to ensure that GPs have digital tools to conveniently refer to appropriate diagnostic tests at local testing centres, and we are enhancing digital connectivity across the NHS to enable results to flow more seamlessly.

A phased approach

The increase in use of direct access tests will be phased. The first phase launched in November 2022 and requires an increase in the use of specific direct access tests for adults who have concerning symptoms, but do not meet the threshold for referral to a specialist or for urgent direct access testing under cancer recognition and referral guidance (NG12). Currently over 20% of cancer diagnoses are made in people referred for investigation on non-urgent pathways – often because their symptoms did not indicate a significant risk of malignancy.

Our aims in phase one are to reduce:

• the time it takes for adults who have concerning symptoms but do not meet the criteria for urgent suspected cancer referral to receive a diagnosis
• the number of GP and specialist attendances before investigations are requested for these patients.

These aims support the implementation of the NHS Long Term Plan ambition for 75% of people with cancer to be diagnosed at an early stage (stage 1 or 2) by 2028, and the elective recovery ambition for 95% of patients needing a diagnostic test to receive it within six weeks by 2025.

We have developed a set of data metrics to monitor progress against these aims and measure outcomes. Regular diagnostics data hub collections will enable us to monitor rates of GP direct access uptake by integrated care system (ICS) and region.

Phase two is intended to begin later in 2023 and will support systems to make a wider range of direct access tests available, including spirometry and fractional exhaled nitric oxide (FeNO) which will help enable faster diagnosis of asthma, chronic respiratory conditions (including chronic obstructive pulmonary disease) and cardiovascular diseases.

About the guidance

This guidance is not a clinical guideline.

It provides advice on the use of urgent direct access referrals to specific diagnostic tests where the threshold for referral under the urgent suspected cancer referral pathway – to a specialist or for urgent GP direct access testing – as outlined by National Institute for Health and Care Excellence guideline NG12 is not met.

This guidance is distinct from NG12 but should be considered alongside it.

The guidance supports the first phase of delivery and is aimed at and of interest to healthcare professionals in primary care, secondary care and service commissioners. It builds on Direct access to diagnostic tests for cancer (2012).

It covers the following diagnostic tests, which all GPs should have access to as a minimum:

• chest X-ray
• CT chest
• CT abdomen and pelvis
• ultrasound abdomen and pelvis
• brain MRI.

It also details expectations around wait and turnaround times for direct access referrals made for this cohort.

Using the guidance

GPs should consider urgent direct access tests where they consider an urgent investigation is required, but do not think an urgent suspected cancer referral is appropriate.

GP direct access arrangements provide another option for GPs to draw on as they manage their patients (NG12 direct access recommendations may be associated with different expectations around wait and turnaround times). They should use their clinical judgement and consider an urgent direct access test as part of a set of wider investigations that explore the common causes of presenting symptoms. This should include a full history and appropriate examination.

GPs should be mindful of health inequalities that evidence shows are specific or relevant to primary care.

We recommend that this guidance is viewed alongside the clinical decision support (CDS) tool iRefer, which can help guide GPs to the most appropriate test, including any sequence of tests that may be required before a GP direct access referral.

We will allocate funding to providers up to 2024/25 to implement the iRefer-CDS system and make licences available to primary care. We will also provide support to ensure that all GP order communications systems are compatible with iRefer-CDS. This aims to ensure best practice in GP referrals for imaging tests, so that patients receive the most appropriate tests and diagnostic capacity is managed.

GPs can continue to use existing direct access workflow, but our expectation is that practices with compatible order communications systems will migrate to iRefer-CDS as soon as licences become available.

Clinical indications by imaging test

Detailed below are the symptoms that may warrant an urgent direct access referral to the tests recommended in this guidance, to guide decision-making.

GPs should continue to use their clinical judgement to decide whether an urgent direct access, urgent cancer referral, non-specific symptoms pathway or routine referral will deliver the best outcomes for their patients. In doing so they should also consider the sequence of tests needed to investigate the common causes of these symptoms, having conducted a full history and appropriate examination.

To support this decision-making, the following table summarises the urgent referral pathways and the eligible populations for each:

We recognise that diagnostic testing can have wider implications. Incidental findings can impact on the individual patient and healthcare resources. When considering referral of a patient for diagnostic testing, GPs may wish to discuss the risks with the patient and are advised to consult iRefer-CDS.

Symptoms that may warrant an urgent direct GP referral for chest X-ray (CXR) or CT chest

Data suggests that the variation in CXR usage by practices does not solely reflect practice populations, and that higher CXR rates are associated with earlier cancer detection. CXR is a low-cost test and there is scope to increase its use as a first line test in lower risk patients, which will include never-smokers and those under the age of 40.

A CT scan has greater sensitivity than CXR for detecting lung cancer. CT is a more accurate test, and some people would still be considered high risk even when the CXR is normal and so will need a CT.

GPs should carefully consider the risk profile of patients when referring for chest imaging. CT should be considered in patients with:  

• unexplained persistent cough (over three weeks), where a normal CXR would not be reassuring
• worsening spirometry
• cervical lymphadenopathy.

GPs can consider further investigation, imaging (including CT) and referral for people who have a normal chest X-ray result but continuing undiagnosed symptoms, regardless of their risk level.

Symptoms that may warrant an urgent direct GP referral for CT abdomen and pelvis or ultrasound abdomen and pelvis

GPs should consider patients’ risk profile and request investigations for the common causes of presenting symptoms, either prior to or alongside a direct access test.

Where GPs consider an urgent direct access test is warranted, they should consult iRefer-CDS to decide whether to refer for ultrasound or CT for the following symptoms:

• pelvic or abdominal pain
• persistent abdominal distension ‘bloating’
• increased urinary urgency and/or frequency
• new onset altered bowel habit (particularly in those over the age of 40)
• feeling full (early satiety) and/or loss of appetite.

These symptoms can reflect several different intra-abdominal cancers including those of the pancreas, colon, urological tract or lymphoma.

of the pancreas, colon, urological tract or lymphoma.

Symptoms that may warrant an urgent direct GP referral for brain MRI

Most patients with primary brain tumours have seen their GP before diagnosis, sometimes several times. However, over 50% are diagnosed following emergency presentation. Only 1% of patients with brain tumour are referred via an urgent suspected cancer pathway. GP access to brain MRI is essential to support the earlier and faster diagnosis of brain tumours in primary care.

Research shows that referral for a suspected brain tumour based on headache alone has a positive predictive value of 0.1%. [1]. This means that headache alone is unlikely to indicate a tumour, but if it clearly progresses in frequency and severity and/or is combined with new neurological symptoms, especially cognitive decline or a combination of symptoms, it may be significant.

GPs should consider whether a brain MRI is warranted for new persistent or progressive headache plus new or progressive:

• cognitive decline/cognitive change
• changes in speech – word finding difficulty, using the wrong words, semantic verbal fluency test (SVFT) score <17 (inability to name at least 17 different animals in 1 minute)
• personality change
• objectively confirmed visual deficits, particularly visual field loss (can be assessed by a high-street optician)
• unilateral arm or leg weakness
• unilateral sensory change.

The threshold for brain imaging should be lower in patients with a previous cancer diagnosis, especially lung, breast, melanoma and renal.

New onset seizures and new onset focal neurological change should continue to be referred via acute pathways.

In young people (20s and 30s), history should include specifically seeking a history of seizures without collapse, for example, vacant episodes or transient sensory or motor change, self-limiting but increasing in frequency and severity. If there are concerns about isolated, progressive headache without other symptoms, CT could be considered.

Wait times

An urgent direct access referral will aim to be completed, including report, in no more than four weeks. This will be achieved through work to increase capacity and enhance digital connectivity across the NHS, to enable results to flow more seamlessly.

It is recommended that radiology departments refer to Diagnostic imaging reporting turnaround times guidance.

Results management

There must be a local pathway in place for escalation so that patients with results indicative of a malignancy are referred via an urgent suspected cancer pathway. This must be quickly and clearly communicated to the referring GP and include details of any information given to the patient.

All GP practices should have robust safety netting processes in place to ensure that all GP direct access imaging results are noted and acted upon, abnormal results suspicious of cancer are urgently referred and the patient is communicated with in a timely manner.

Incidental and equivocal findings

Local systems should have standard operating procedures, significant findings policies and/or pathways in place to deal with unexpected and significant incidental findings.

The reporting of results should make specific recommendations for any action required by primary care. This is achieved through an effective two-way exchange of information between primary care and radiology departments and includes:

The patient should have their results explained by a clinician.

Acknowledgments

The following were consulted during the development of this guidance:

• The Royal College of Radiologists
• The Royal College of General Practitioners
• The Society of Radiographers

The following contributed to the development of this guidance:

• NICE Clinical Lead for referral for suspected cancer guideline (NG12)
• National Clinical Director for Cancer
• National Specialty Advisor for Imaging
• Getting It Right First Time Clinical Lead for Radiology
• National Clinical Director for Neurology
• Getting It Right First Time Lead for Neurology
• Consultant Clinical Oncologist, The Christie NHS Foundation Trust
• Regional radiology leads
• Head of Imaging Transformation
• NHS England Primary Care Group
• NHS England Cancer Programme

Publication reference: PR1945