- Stephen H Bradley, NIHR academic clinical lecturer1,
- Daniel Jones, general practitioner12,
- Su Wood, academic pharmacist1,
- Meena Rafiq, academic general practitioner3 4,
- Carolyn Bradley, patient5,
- William T Hamilton, professor of primary care diagnostics6
1Academic Unit of Primary Care, University of Leeds, UK
2North Cumbria Integrated Care NHS Foundation Trust, Carlisle, UK
3Centre for Cancer Research and Department of General Practice, University of Melbourne, Australia
4Epidemiology of Cancer and Healthcare Outcomes (ECHO) group, University College London, UK
5Patient author, Leeds, UK
6Department of Health and Community Sciences, Faculty of Health and Life Sciences, University of Exeter, UK
- Correspondence to: S H Bradley medsbra{at}leeds.ac.uk
Cancer is diagnosed at more advanced stages, and consequently with poorer outcomes, in the UK than in many other high income countries.1234 Although these disparities have been observed over decades, worsening access to general practice appointments, particularly since the coronavirus pandemic, has led to concern that people with cancer symptoms are experiencing additional delays to diagnosis. Achieving timely diagnosis for many cancers is crucial to improving outcomes as even relatively short delays are associated with reduced likelihood of survival.5
Involving community pharmacy in detecting symptomatic cancer has long been proposed as a means of expediting diagnosis.6 In 2022 England’s NHS announced ambitious plans to enable community pharmacists to arrange tests for possible cancer symptoms,7 although the ongoing pilot schemes have adopted a more limited approach.8 Managing people presenting with possible cancer is not straightforward, and community pharmacies already struggle to meet high levels of demand. Even if substantially increased numbers of cancer referrals are made through community pharmacy, it will not solve the problem of delays for diagnostic services. It therefore seems unlikely that involving community pharmacy will transform how cancer is diagnosed in primary care.
What is the rationale for involving community pharmacy?
Announced as a way to “transform the way we find and treat cancer,” the NHS policy initially promised that patients attending pharmacies “will be referred direct for scans and checks without needing to see a GP if staff think it could be cancer.”7 However, according to the specification for the pilot scheme, which is restricted to pharmacies in three areas of England, pharmacies will arrange referrals either for urgent hospital assessment or to their GP, depending on symptoms (supplementary table), rather than arranging tests directly. Nevertheless, the prospect of community pharmacies detecting cancer, including the autonomy to refer directly for diagnostic tests, continues to have salience, having been supported in reports by the pharmacy professional organisation the Royal Pharmaceutical Society and two health policy think tanks, the King’s Fund and Nuffield Trust.910
Community pharmacies can be accessed without appointments and are located within a 20 minute walk of over 98% of those living in the most deprived tenth of England’s population.11 Therefore pharmacies could have a role in reaching those who may face barriers to accessing general practice. A 2015 systematic review examining factors influencing timeliness of help seeking for possible cancer symptoms, found that awareness of possible cancer symptoms is lower among more deprived populations, who also take longer to present to medical services when they have symptoms.12 Such people may instead seek advice or over-the-counter treatments for problems like cough or indigestion,1314 leading policy makers to believe that “pharmacies are well placed to spot people presenting with ‘red flag’ potential cancer symptoms.”15
Pharmacies already deliver a wide and increasing range of services, including vaccinations, treatments for minor ailments, and dispensing emergency contraception. The skills and potential of community pharmacists to provide an even broader range of primary care services, including diagnosis and management of chronic disease, have arguably been underused.16 In response to challenges around access to primary care services, NHS England has announced an expanded role for community pharmacy, including permitting pharmacists to prescribe medications for common conditions.17
Evidence on community pharmacy diagnosis
Evidence on detection of cancer in people presenting to pharmacies with symptoms is limited. A 2015 systematic review of education and screening initiatives in community pharmacies concluded that there is “significant potential” for pharmacies to promote early diagnosis of cancer.18 However, only two of the 15 included studies examined interventions to aid cancer detection in symptomatic people, both of which were Australian evaluations of questionnaires to help community pharmacists decide which customers with lower gastrointestinal symptoms should be advised to consult a GP.1920 The studies involved 16 and 21 community pharmacies, respectively, and reported that 18/109 and 8/91 patients were directed to consult with their GP.
A study published in 2015 in 33 English pharmacies suggested it is feasible for staff to be trained to recognise possible cancer presentations. Over the six month study period 642 people with possible cancer symptoms (mean three per pharmacy per month) were identified. Persistent cough was overwhelmingly the most common symptom reported (46%).21 In the UK, three studies have evaluated initiatives to enable pharmacists to identify and refer people for chest radiography2223 or to a hospital clinic for further assessment.24 In total 69 pharmacies were involved, with 69 people referred for investigation, equating to 0.06-0.4 patients per pharmacy per month having a chest x ray examination. Respiratory symptoms are extremely common in the community25 and are likely to be experienced by a substantial proportion of those who attend community pharmacies. The low referral rates observed in these schemes could therefore reflect barriers such as limited time available to staff in pharmacies to take on additional tasks. With such low frequency of referrals staff may struggle to develop and maintain necessary skills in history taking and symptom appraisal.
Implications for workforce and skills in community pharmacy
Community pharmacies are already finding it challenging to deliver their core services. The sector faces similar workload pressures and staff shortages as general practice. Over 70% of pharmacies report shortages of pharmacists, and almost 20% have had to temporarily close because of inadequate staffing.26 The idea that pharmacies represent an “untapped resource” that is “ready to roll” is therefore optimistic.27
The pilot scheme will require pharmacy staff to identify, appraise, and organise referral according to a wide range of symptoms (supplementary table). This is all the more challenging since several presentations require pharmacists to decide whether symptoms are “unexplained.” Furthermore, identification of people who may require a pharmacist consultation is likely to fall to non-clinically trained staff, who field most customer interactions in community pharmacy. Cancer recognition could be simplified by asking staff to identify single “red flag” symptoms for each cancer that reflect a risk sufficiently high to consider referral. However, not all cancers have such symptoms, and they occur in only a minority of cases.28
Recognising possible cancer symptoms is vital, but it is only one step within the clinical consultation. Clinicians also need to ascertain additional information to appraise symptoms, weigh up the likelihood of alternative diagnoses, including other serious illnesses, before formulating a plan along with their patient. Finally, such discussions may lead to follow-up or “safety netting” advice informed by an understanding of the possibility of false negative test results or the symptoms being caused by other disease processes that may not be identified by a cancer targeted test.2930
The number of informal consultations community pharmacists deliver is increasing, and currently stands at around 20 a day, each lasting about six minutes.31 Consultations for cancer symptoms are likely to be more time consuming—for example, assessment for referral to chest radiography in pharmacy takes over twice this time.22 Even if staff in community pharmacies receive training to assess for cancer symptoms, they may not have time to deliver such consultations at scale.
Logistical and governance considerations
Community pharmacies in England typically have at least one room for confidential discussions,32 but many would require additional consulting space if such consultations became more frequent. Pharmacists would also need access to the primary care electronic health records, both to check if relevant investigations had already been undertaken and to document consultations and management plans. Progress towards greater connectivity between community pharmacy and general practice systems has been achieved as part of another scheme.33
Similarly, processes for organising tests and referrals from pharmacies may be more robust if they were connected to hospital systems for requesting tests and receiving results (or of patients’ non-attendance). Maintaining familiarity with often cumbersome systems may not be tenable for pharmacists requesting referrals or tests only occasionally. Even if routine access to primary and secondary care systems was achieved, challenges to care coordination would remain. Monitoring of results and attendance could fall to general practices, but such expectations have previously proved controversial and would need to be negotiated carefully.34
It can be argued that patients receiving tests through pharmacies might not otherwise have had their symptoms investigated at all, but it cannot be assumed that lower standards for safe clinical management and follow-up are acceptable to patients or regulators. Offering cancer testing could expose pharmacists to greater risks of complaints or litigation, perhaps for failing to organise or follow up on cancer tests, which would affect indemnity costs and the preparedness of pharmacists to take on such responsibilities. The General Pharmaceutical Council requires pharmacists to “recognise and work within the limits of their knowledge and skills, and refer to others when needed.”35 Participating pharmacists would need to satisfy themselves that they had received sufficient training to be considered competent to be responsible for requesting cancer tests, although this could prove challenging for individuals to determine.
Community pharmacies face a highly competitive commercial environment, dominated by large national and multinational chains. They will need to be offered sufficient reimbursement to justify taking on additional clinical responsibilities, which could amount to substantial costs overall. English pharmacies taking part in the scheme to treat seven common conditions receive an initial payment of £2000 (€2300; $2500) followed by monthly payments of £1000 if a minimum number of consultations are carried out.36 The cancer detection pilot includes a one-off set-up payment of £390, along with a monthly payments of between £329 and £411 depending on the number of consultations undertaken.8 Evaluation of the pilot will help understand whether these payments are sufficient to get pharmacies to participate.
Involving pharmacists will not alleviate backlogs for cancer diagnostics
Capacity problems in general practice have created an access bottleneck, with patients facing difficulties and delays in obtaining appointments. Patients with possible cancer symptoms who are referred for investigations, such as endoscopy or computed tomography, are likely to then encounter a second bottleneck.3738 Involving community pharmacy in referring people with potential cancer symptoms for investigations would help alleviate only the first bottleneck, and reductions in overall delays to diagnosis may be slight, particularly if increases in referrals for suspected cancer leads to greater delays overall.
Although widening access to referrals or tests through pharmacies might benefit some people, it could also expose others to risks such as incidental diagnoses that would never have produced symptoms (overdiagnosis).39 Understanding benefits as well as potential risks of testing should inform decisions made by clinicians with patients around testing. If community pharmacists had lower thresholds to request testing or referral—for example, because of incentives or less time available and the experience of managing test results—this could increase risk of adverse consequences such as overdiagnosis and health service costs. However, evidence from the pilot schemes for lung cancer has indicated that pharmacists arrange tests infrequently.222324
Community pharmacies have extensive reach, particularly in deprived communities, and are the first port of call for many people seeking help for symptoms. However, they are already struggling to meet demand for existing services. Appraising possible cancer symptoms and deciding with the patient on any need for action requires time, expertise, and access to clinical infrastructure, including electronic health records. Objective evaluation of the NHS pilot will be essential to understand the extent of the opportunities that exist for recognising possible cancer symptoms in community pharmacy and whether such initiatives can feasibly be delivered across the sector.
Key messages
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Difficulties in accessing primary care have led to concerns that cancer diagnoses are being delayed
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In response NHS England has announced plans to enable community pharmacies to arrange referrals for people with possible cancer symptoms, with pilots under way
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Pharmacies are already overstretched and will require the skills and facilities to safely appraise people with cancer symptoms
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Increased referrals could exacerbate the bottlenecks in diagnostic investigations
Acknowledgments
We thank Simon Gordon, Søren Gray Worsøe Laursen, Javiera Martinez Gutierrez, Chisato Hamashima, Patrick Redmond, Matthew Thompson, and Niek de Wit who provided advice on cancer diagnosis in countries other than the UK and Australia. We also to thank Wasim Baqir and Ziad Laklouk from NHS England for information on the community pharmacy cancer diagnosis pilot programme.
Footnotes
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Contributors and sources: SHB, MR, DJ, and WTH are academic general practitioners with a research focus on cancer diagnosis in primary care. SW is an academic pharmacist who has led research focusing on improving patient safety and has worked as a pharmacist in primary care. CB is a patient who was diagnosed with cancer roughly a year after first presenting with symptoms to her GP when a physiotherapist requested an x ray examination. SHB prepared the first draft of the manuscript with co-authors providing revisions. We also consulted colleagues from Chile, Denmark, France, Israel, Japan, the Netherlands, the Republic of Ireland, and the United States to find international precedents. SHB is the guarantor.
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Patient and public involvement: CB, a patient who has experienced diagnostic delay for cancer, is a co-author, contributing insights during preparation of the initial draft and helping to revise the manuscript along with all other co-authors.
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Competing interests: We have read and understood BMJ policy on declaration of interests and have the following interests to declare: SHB is clinical lead for cancer for Leeds Office of West Yorkshire Integrated Care Board. In this role he has supported a scheme to facilitate community pharmacists to advise patients with common respiratory symptoms to have a chest x ray. During 2017-21 he was an executive committee member of the Fabian Society, a political think tank affiliated to the UK Labour party. In this role he co-edited a series of essays on health inequalities, the publication costs of which were paid for by the Association of the British Pharmaceutical Industry and Lloyd’s pharmacies. WTH sits on a primary care advisory group for NHS England and has advised on the current pilot of pharmacy cancer detection. He is a co-applicant on an NIHR funded study aiming to optimise colorectal cancer detection through pharmacies. All authors are writing in a personal capacity, and opinions expressed here should not be considered to represent the views of any organisation to which the authors have an affiliation.
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Provenance and peer review: Not commissioned; externally peer reviewed.