Is cancer survival associated with cancer symptom awareness and barriers to seeking medical help in England? An ecological study.

BACKGROUND: Campaigns aimed at raising cancer awareness and encouraging early presentation have been implemented in England. However, little is known about whether people with low cancer awareness and increased barriers to seeking medical help have worse cancer survival, and whether there is a geographical variation in cancer awareness and barriers in England. METHODS: From population-based surveys (n=35 308), using the Cancer Research UK Cancer Awareness Measure, we calculated the age- and sex-standardised symptom awareness and barriers scores for 52 primary care trusts (PCTs). These measures were evaluated in relation to the sex-, age-, and type of cancer-standardised cancer survival index of the corresponding PCT, from the National Cancer Registry, using linear regression. Breast, lung, and bowel cancer survival were analysed separately. RESULTS: Cancer symptom awareness and barriers scores varied greatly between geographical regions in England, with the worst scores observed in socioeconomically deprived parts of East London. Low cancer awareness score was associated with poor cancer survival at PCT level (estimated slope=1.56, 95% CI: 0.56; 2.57). The barriers score was not associated with overall cancer survival, but it was associated with breast cancer survival (estimated slope=-0.66, 95% CI: -1.20; -0.11). Specific barriers, such as embarrassment and difficulties in arranging transport to the doctor's surgery, were associated with worse breast cancer survival. CONCLUSIONS: Cancer symptom awareness and cancer survival are associated. Campaigns should focus on improving awareness about cancer symptoms, especially in socioeconomically deprived areas. Efforts should be made to alleviate barriers to seeking medical help in women with symptoms of breast cancer.

Changes in patient experience associated with growth and collaboration in general practice: observational study using data from the UK GP Patient Survey.

BACKGROUND: For the last few years, English general practices - which are, traditionally, small - have been encouraged to serve larger populations of registered patients by merging or collaborating with each other. Meanwhile, patient surveys have suggested that continuity of care and access to care are worsening. AIM: To explore whether increasing the size of the practice population and working collaboratively are linked to changes in continuity of care or access to care. DESIGN AND SETTING: This observational study in English general practice used data on patient experience, practice size, and collaborative working. Data were drawn from the English GP Patient Survey, NHS Digital, and from a previous study. METHOD: The main outcome measures were the proportions of patients at practice level reporting positive experiences of both access and relationship continuity of care in the GP Patient Survey. Changes in proportions between 2013 and 2018 among practices that had grown and those that had, roughly, stayed the same size were compared, as were patients' experiences, categorised by whether or not practices were working in close collaborations in 2018. RESULTS: Practices that had grown in population size had a greater fall in continuity of care (by 6.6%, 95% confidence interval = 4.3% to 8.9%), than practices that had roughly stayed the same size, after controlling for other factors. Differences in falls in access to care were smaller (4.3% difference for being able to get through easily on the telephone; 1.5% for being able to get an appointment; 0.9% in satisfaction with opening hours), but were statistically significant. Practices collaborating closely with others had marginally worse continuity of care than those not working in collaboration, and no differences in access. CONCLUSION: Larger general practice size in England may be associated with slightly poorer continuity of care and may not improve patient access. Close collaborative working did not have any demonstrable effect on patient experience.

How widespread is working at scale in English general practice? An observational study.

BACKGROUND: Over the last 5 years, national policy has encouraged general practices to serve populations of >30 000 people (called 'working at scale') by collaborating with other practices. AIM: To describe the number of English general practices working at scale, and their patient populations. DESIGN AND SETTING: Observational study of general practices in England. METHOD: Data published by the NHS on practices' self-reports of working in groups were supplemented with data from reports by various organisations and practice group websites. Practices were categorised by the extent to which they were working at scale; within these categories, the age distribution of the practice population, level of socioeconomic deprivation, rurality, and prevalence of longstanding illness were then examined. RESULTS: Approximately 55% of English practices (serving 33.5 million patients) were working at scale, individually or collectively serving populations of >30 000 people. Organisational models representing close collaboration for the purposes of core general practice services were identifiable for approximately 5% of practices; these comprised large practices, superpartnerships, and multisite organisations. Approximately 50% of practices were working in looser forms of collaboration, focusing on services beyond core general practice; for example, primary care in the evenings and at weekends. Data on organisational models and the purpose of the collaboration were very limited for this group. CONCLUSION: In early 2018, approximately 5% of general practices were working closely at scale; approximately half of practices were working more loosely at scale. However, data were incomplete. Better records of what is happening at practice level should be collected so that the effect of working at scale on patient care can be evaluated.

The role of the Quality and Outcomes Framework in the care of long-term conditions: a systematic review.

BACKGROUND: Improving care for people with long-term conditions is central to NHS policy. It has been suggested that the Quality and Outcomes Framework (QOF), a primary care pay-for-performance scheme that rewards practices for delivering effective interventions in long-term conditions, does not encourage high-quality care for this group of patients. AIM: To examine the evidence that the QOF has improved quality of care for patients with long-term conditions. DESIGN AND SETTING: This was a systematic review of research on the effectiveness of the QOF in the UK. METHOD: The authors searched electronic databases for peer-reviewed empirical quantitative research studying the effect of the QOF on a broad range of processes and outcomes of care, including coordination and integration of care, holistic and personalised care, self-care, patient experience, physiological and biochemical outcomes, health service utilisation, and mortality. Because the studies were heterogeneous, a narrative synthesis was carried out. RESULTS: The authors identified three systematic reviews and five primary research studies that met the inclusion criteria. The QOF was associated with a modest slowing of both the increase in emergency admissions and the increase in consultations in severe mental illness (SMI), and modest improvements in diabetes care. The nature of the evidence means that the authors cannot be sure that any of these associations is causal. No clear effect on mortality was found. The authors found no evidence that the QOF influences integration or coordination of care, holistic care, self-care, or patient experience. CONCLUSION: The NHS should consider more broadly what constitutes high-quality primary care for people with long-term conditions, and consider other ways of motivating primary care to deliver it.

"Promoting Early Presentation" intervention sustains increased breast cancer awareness in older women for three years: A randomized controlled trial.

Objective In a randomized controlled trial, the Promoting Early Presentation intervention increased older women's breast cancer awareness after two years. We investigated whether this increase was sustained at three years, and the effect on breast screening self-referral. Methods We randomly allocated 867 women attending their final invited breast screening appointment to the Promoting Early Presentation intervention or usual care. We examined breast cancer awareness after three years and breast screening self-referrals after four years. Results Women in the Promoting Early Presentation intervention arm had higher breast cancer awareness at three years than the usual care arm (odds ratio: 10.4; 95% confidence interval: 3.1 to 34.8). There were no differences in proportions self-referring for breast screening between arms, but statistical power was limited. Conclusion The Promoting Early Presentation intervention has a sustained effect on breast cancer awareness in older women. The effect on self-referral for breast screening is unclear.

Delays in diagnosis of young females with symptomatic cervical cancer in England: an interview-based study.

BACKGROUND: Diagnosis may be delayed in young females with cervical cancer because of a failure to recognise symptoms. AIM: To examine the extent and determinants of delays in diagnosis of young females with symptomatic cervical cancer. DESIGN AND SETTING: A national descriptive study of time from symptoms to diagnosis of cervical cancer and risk factors for delay in diagnosis at all hospitals diagnosing cervical cancer in England. METHOD: One-hundred and twenty-eight patients <30 years with a recent diagnosis of cervical cancer were interviewed. Patient delay was defined as ≥3 months from symptom onset to first presentation and provider delay as ≥ 3 months from first presentation to diagnosis. RESULTS: Forty (31%) patients had presented symptomatically: 11 (28%) delayed presentation. Patient delay was more common in patients <25 than patients aged 25-29 (40% versus 15%, P = 0.16). Vaginal discharge was more common among patients who delayed presentation than those who did not; many reported not recognising this as a possible cancer symptom. Provider delay was reported by 24/40 (60%); in some no report was found in primary care records of a visual inspection of the cervix and some did not re-attend after the first presentation for several months. Gynaecological symptoms were common (84%) among patients who presented via screening. CONCLUSIONS: Young females with cervical cancer frequently delay presentation, and not recognising symptoms as serious may increase the risk of delay. Delay in diagnosis after first presentation is also common. There is some evidence that UK guidelines for managing young females with abnormal bleeding are not being followed.

A systematic review of barriers to early presentation and diagnosis with breast cancer among black women.

OBJECTIVE: To explore barriers to early presentation and diagnosis with breast cancer among black women. DESIGN: Systematic review. METHODS: We searched multiple bibliographic databases (January 1991-February 2013) for primary research, published in English, conducted in developed countries and investigating barriers to early presentation and diagnosis with symptomatic breast cancer among black women (≥18 years). Studies were excluded if they did not report separate findings by ethnic group or gender, only reported differences in time to presentation/diagnosis, or reported on interventions and barriers to cancer screening. We followed Cochrane and PRISMA guidance to identify relevant research. Findings were integrated through thematic synthesis. Designs of quantitative studies made meta-analysis impossible. RESULTS: We identified 18 studies (6183 participants). Delay was multifactorial, individual and complex. Factors contributing to delay included: poor symptom and risk factor knowledge; fear of detecting breast abnormality; fear of cancer treatments; fear of partner abandonment; embarrassment disclosing symptoms to healthcare professionals; taboo and stigmatism. Presentation appears quicker following disclosure. Influence of fatalism and religiosity on delay is unclear from evidence in these studies. We compared older studies (≥10 years) with newer ones (<10 years) to determine changes over time. In older studies, delaying factors included: inaccessibility of healthcare services; competing priorities and concerns about partner abandonment. Partner abandonment was studied in older studies but not in newer ones. Comparisons of healthy women and cancer populations revealed differences between how people perceive they would behave, and actually behave, on finding breast abnormality. CONCLUSIONS: Strategies to improve early presentation and diagnosis with breast cancer among black women need to address symptom recognition and interpretation of risk, as well as fears of the consequences of cancer. The review is limited by the paucity of studies conducted outside the USA and limited detail reported by published studies preventing comparison between ethnic groups.