Ade Williams, lead pharmacist at Bedminster Pharmacy in Bristol, writes about how community pharmacy can – and should – contribute to tackling the backlog in cancer diagnosis and treatment in the wake of the Covid-19 pandemic.
As a community pharmacist, my most treasured privilege are the innumerable life interactions with our community. We do life together, riding the emotions, with me always seeking to offer comfort and care.
Sadly, there is a moment that gets played out too many times, each one etched in my heart.
A familiar face walks in. I notice something in their eyes, their demeanour, a slumped shoulder. I walk over, abandoning whatever I was doing. We sit in the consultation room. Often, with the most dignified delivery, I get the news. That one medical diagnosis – the dreaded C word – yes, cancer.
Last year, as the coronavirus pandemic took hold, like many others, I feared the impact of the necessary suspension of usual referral pathways coupled with lower uptake or availability of routine screening appointments.
Sometimes this is solely due to capacity limitations, yet many are just unable to surpass the barriers built by the trauma of images and news of deaths in the places associated with life-preserving care and restoration. As a result, planned investigative appointments are held off.
Fewer referrals equal more deaths
Last October, Macmillan Cancer Support estimated that there were around 50,000 ‘missing diagnoses’ across the UK – meaning 50,000 fewer people had been diagnosed with cancer to that point in 2020, compared with a similar timeframe in 2019.
The charity’s report highlighted that, in 2020, thousands fewer people had started treatment after a cancer diagnosis than in 2019. In England alone, between March and August 2020, around 30,000 fewer people had started their first cancer treatment compared than had done the year before.
We’ve had two more lockdowns since that report. The measure of the crisis now faced is summed up in the document Catch Up With cancer – The Way Forward.
This paper is the work of chairs of the All-Party Parliamentary Group (APPG) for Radiotherapy, the APPG on Health, and other cancer-focused APPGs. They held a joint consultation between 30 April and 25 May this year to gather recommendations from frontline staff, associated organisations and stakeholders on solutions to tackle the Covid-induced cancer backlog.
It makes for very sober reading: cancer experts warning that the Covid-induced cancer backlog could lead to tens of thousands of extra deaths; referrals of suspected cancer falling by 350,000 in March to August 2020 compared with the same period in 2019; some 40,000 fewer people than normal starting cancer treatment, echoing Macmillan’s stark finding.
I am conscious that among community pharmacy colleagues reading this, empathy assured, many are unmindful of how our work has helped, and continues to help, to make the situation better. Sadly, this is also not widely acknowledged directly.
Broad shoulders of community pharmacy
When general practice moved to new ways of working, the bulk of face-to-face consultations fell on the shoulders of community pharmacy. To diminish this to a comparative, point-scoring, workload-shift issue would be wrong. Colleagues in general practice for the first time saw the full depth of expertise and innovation in community pharmacy, relying on us to take on care previously shared differently in primary care.
The gateway of the NHS – primary care – may have buckled, but it didn’t break.
Data from a PSNC audit provides a measure of the reliance that the public has had on pharmacies through the Covid-19 pandemic.
The headline figures are truly staggering.
On average, pharmacies undertake 17 consultation per day. That totals around 1.12 million consultations per week, or more than 58 million per year (based on 11,100 community pharmacies in England across six days per week).
Each week, just under 130,000 informal referrals from general practice and NHS11 are received into pharmacy. The emerging picture from the rollout of the community pharmacy consultation service (CPCS) is now helping us to better understand its adoption challenges and possibly some design gaps.
Every week pharmacies provided advice to more than 730,000 people (nearly 38 million people per year) who were seeking advice for symptoms.
In 12.4% of consultations, patients are referred to another healthcare professional, such as their GP practice.
We must of course look at these figures through the lens of the Covid pandemic. However, they demonstrate what community pharmacy has always done, but this time under unprecedented demand and strain.
Maximising our position
Two areas immediately jump out to me. Firstly, the informal referrals. How do we close the loop to ensure that clinical details are captured and shared in a fair, consistent model as part of the funded care community pharmacy offers? Some of these clinical presentations may also warrant urgent onward investigative referrals.
I am on the record as advocating for community pharmacy to be able to make clinically appropriate two-week cancer referrals, especially in communities where health inequalities, historical exclusion and/or socioeconomic discrimination and racism exist.
Secondly, I refer to the 12.4% of consultations where patients are referred on to another healthcare professional such their GP.
In Bristol, North Somerset and South Gloucestershire – my local patch – a University of Bristol study funded by the National Institute for Health Research (NIHR) examined over-50s reporting possible cancer symptoms to their GP. It covered 21 GP practices with 124,000 patients in that age group. The study found that in the period April to July 2020, the number of patients over the age of 50 reporting possible cancer symptoms to their GP fell by 36%, compared with the same period in 2019.
One of my pains over the last few months has been how the pandemic has unmasked the inherent weakness that continues to plague us while our care systems are fragmented and unaligned.
I certainly know from my own work and discussions with many colleagues that cancer patients were presenting in community pharmacy. As an ambassador of the charity Pancreatic Cancer Action, I am ever aware of non-specific cancer symptoms and will use informal, locally agreed referral pathways into general practice where possible and where patients have consented.
I am also mindful that a significant proportion of the patients who are now presenting in local GP practices are following on from those consultations in community pharmacy. This is the delayed onward action of the self-referral advice.
The backlog and workload faced by everyone in the NHS, exhausted from the ongoing work to protect the nation from the pandemic, is making the situations even more dire.
Cancer doesn’t stop
During the pandemic, cancer never stopped. Early diagnosis is universally accepted as crucial for best treatment outcomes. Those conversations that used to fill me with much dread have morphed into statistics-led cancer headlines.
For the sake of those we can no longer offer care to and have journeyed on without our goodbyes, I will continue to work to increase the speed, equity and ease of cancer diagnoses alongside providing much-needed reassurance to the majority of people.
Sadly, as I comb through policy and research papers, it remains evident that many people still need to understand and discover the importance of community pharmacy in unlocking early cancer diagnosis. This lack of acknowledgment is a sinking weight.
Thank you, community pharmacy, for always making time to provide evidence-based care, following up referred patients and giving them comfort. We must all now tackle the barriers and build the bridges needed to create workable, sustainable change. That’s what’s needed to improve early diagnosis and make the most of the unique strengths of community pharmacy.