COMMENTARY

What's Wrong With NHS Cancer Imaging Services?

Prof Karol Sikora

Disclosures

July 16, 2021

This transcript has been edited for clarity.

Hello, I'm Professor Karol Sikora, and I'm talking today about diagnostic imaging. I'm an oncologist and have been a consultant for 40 years and imaging is now just fantastic compared with what it was before. And it's really the entry point for most patients with cancer into treatment.

There's a report that's just come out from the Parliamentary and Health Service Ombudsman entitled Unlocking Solutions in Imaging: working together to learn from failings in the NHS.

And a summary of it – it’s a bit of self-flagellation by the NHS - it's saying we're not actually doing that well, and there's ways we can improve it.

And I think it is quite a constructive report.

Errors

The Parliamentary Ombudsman has gathered 25 cases - which are outlined in detail - where errors have been made. Failings in either communication of imaging results, or the loss of imaging results that was significant to the patient.

So let me give you an example. Case study number one, and some of these case studies are in the report. Case study number one, patient with breast cancer in August 2017, and 2 years later, when they reviewed the scans, there was also pancreatic cancer right at the beginning. The patient had been ignored by the radiologists. They were asked to stage the breast cancer, they did that. They didn't report on the pancreatic cancer.

And you know, this is contrary to College of Radiologists' Guidelines, which say you’re supposed to report on anything unusual anywhere else on the image. And despite repeated scans, the pancreas lesion was missed consistently.

Presumably because no one was particularly looking for it. The trust didn't take any action after this, and they offered the patient £2500. It's sort of derisory, and the family were really upset.

As always, this could go to medical litigation, a case like that, and we're talking about sums probably in the order of £200,000 if the patient was successful, if you can prove breach of duty, which almost certainly there was. The hospital would find it difficult not to admit that because of its administrative policies with imaging, but more importantly causation. And that's where it's difficult because anyone with pancreatic cancer, on the balance of probabilities, is more likely to die than not die because their 5 year survival is less than 3% overall. So by definition, pancreatic cancer carries such a poor prognosis that proving there was a delay of even 2 years doesn't really make a big difference to the outcome. But that is a difficult concept to get over to distressed relatives that have been told an error has been made. So, we've got to learn to avoid these.

Scans

There are 25 cases, different ones, different types of error, that are in this report. And it reflects the way in which radiology has got swamped, in my experience. There’s too much activity going on.

In the private sector, each scan counts as a product. So people are taking money for doing a specific scan. In the NHS, you've got this fierce pressure of a backlog and under capacity in CT, in MRI, and in PET CT. There is under, whatever metric you use, number of doctors, number of radiographers, number of machines, number of scanning hours per week, where our data is always adverse compared to other countries of similar wealth.

For example, mainland Europe, and certainly way below the capacity in the United States, which is in many ways overladen.

It's very interesting. We look at different setups and different ways of paying for imaging. If you go to the Gulf countries, for example, if you walk around Dubai, they're overloaded with scanners, they always have been of all sorts. You can get a scan this very afternoon. And in fact, in Harley Street, you can do the same. You can walk down there, there are something like 50 scanners with either MR or CT within 100 yards of Harley Street on either side. The typical medical district of London.

Business-like Skills

What we need to do is to get that business-like skill of the private sector to smarten up the NHS. Everything in the private sector gets reported within 48 hours. If it didn't, they wouldn't sell the results. They wouldn't be able to carry on working. Within the NHS, we have all sorts of things going on which make it much more difficult to control. And the quality of radiology is sometimes variable. In some hospitals locums are filling in, they come and go, and people don't even know who has reported the film sometimes. So there's no doubt imaging is clearly something that needs to be smartened up, not just the machines and their capacity, but also the whole reporting structure.

Conclusions

What did the Ombudsman find? Well he came to four conclusions.

The first was, there was failure to follow national guidelines on reporting unexpected imaging findings. I gave a good example of that with a breast patient sent for staging who had concomitant pancreatic cancer.

So, as it says, there are opportunities to spot serious health conditions that have been missed.

Failure to act on unexpected findings. So half the cases show that local trust policies don't really show that if you've got an unusual finding, you have to act on it. You may have to request a further image, you may have to request further investigations, and endoscopy, blood work, and so on.

Delays in reporting imaging findings. In a third of the cases, there were serious delays. We're not talking about days, we're talking about months on getting X-rays reported.

Here, you have fantastically sophisticated scanning equipment, and you get the result either on a disk or in the PACS system - the picture archiving system - and no one's looking at the image. And the consultant physician or surgeon that's requested that image, therefore assumes there's nothing serious going on.

And that's the problem. It's a sort of negative feedback. If you don't get news, you think it's OK. There’s no confirmation that a scan is actually OK.

And then the failure to learn from past mistakes. Time and time again, and I've seen it in my days as a consultant in the NHS, we don't learn from past mistakes. So they occur again and again, to the detriment of patients.

Recommendations

What are the recommendations? Well, there are a series of recommendations that come out of this. Really, the summary of it all, other than a whole load of words of NHS institutions that I'm sure will be gone by the next 2 years once there's been some reform going on. 

Basically, someone has to take responsibility, the clinical directors have the grand responsibility for the not just the processing, and the carrying out of an image, but the reporting of that image, and the way in which that image is reported back to the requesting consultant, or physician.

One of the problems of course, is if it's not a consultant, if it's a locum consultant, or a doctor in training, that's fine. They're perfectly competent to request an image, but there may not be the feedback loop to make sure receipt has been obtained from the patient.

So clearly, a lot of room for improvement.

Sad to read this at a human level, but we can do it, we can do it within the NHS. It just requires a much more cohesive effort than worrying about some of the issues we worry about in the NHS. This one is really the key to early cancer diagnosis and avoiding, perhaps, the most serious error, which is to have to tell someone that we're very sorry, you did have a potentially curable cancer 2 years ago, but now it's no longer curable. That is one of the saddest conversations to have, and almost unbelievable to patients and to their carers and families.

Professor Sikora here. If you have any thoughts about this report, it's certainly worth a read. It's well written, it’s not long, and its conclusions and action points are really, in my opinion, very valid. Thank you for listening.

You can follow Prof Karol Sikora on Twitter

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