Why we need to replace the Two-Week Wait

NHS England has a target that people should wait no more than two weeks for an appointment with a specialist after seeing their GP with symptoms of cancer. But this Two-Week Wait target is not helping people in the way that it should. We look at why this is, and what can be done.

For a person worried about symptoms which could be cancer, the wait to get a diagnosis can be filled with anxiety. Early diagnosis and prompt treatment are also crucial for improving survival from the disease.

To help ensure a quick diagnosis and treatment, NHS England has a set of cancer waiting time standards – targets which represent every step of a person’s cancer experience, from referral, to diagnosis, to treatment. The aim is to make sure that everyone gets good care, no matter who they are, where they live, or what cancer they might have.

One of the best-known targets is the ‘Two-Week Wait’, for people who are urgently referred for further tests at a hospital because their GP suspects they could have cancer or because the results of a cancer screening programme show they may have cancer. The target is that 93% of these people should have an appointment with a cancer specialist within two weeks (14 days) of their GP referral.

The target can help people receive a faster diagnosis, but there are some significant downsides to the Two-Week Wait.

Firstly, the target is about seeing a specialist, not getting a diagnosis. The first appointment with a specialist ‘stops the clock’ on the waiting time target, even if the person requires further tests to receive a result. This means people often wait for longer than two weeks to find out whether or not they have cancer.

Secondly, the Two-Week Wait can mean that people don’t get the tests they need in a timely manner. For example, for breast cancer, the recommended process for diagnosis is the ‘triple assessment’, where a physical examination, a scan of the breasts and, if needed, a biopsy takes place during one appointment. However, 3 in 10 trusts in England provide these as separate appointments, with the first appointment ‘stopping the clock’, allowing the Two-Week Wait target to be met.

For people worried about breast symptoms, having to attend and await the results of three appointments, rather than just one, adds extra anxiety as well as inconvenience.

Thirdly, the Two-Week Wait can prevent innovation in cancer diagnosis. New sophisticated tests are available for diagnosing some cancers, but the results sometimes take longer than two weeks to be returned to doctors. So, to meet the two-week target, sometimes hospitals forgo these newer tests in favour of older ones which return results sooner. As a result, innovative tests are not rolled out as widely as they could be.

The Two-Week Wait target isn’t being met in Yorkshire or the rest of England. Currently, in our region, 83.2% of people are being seen by a specialist within 14 days, which is better than England (75.6%), but still a way behind the target of 93%. In Leeds, only 68.0% of people are seen within the target timeframe.

Because of the COVID pandemic, these targets haven’t been met since May 2020. And according to the latest data from August 2022, there’s no sign of the target being met any time soon.

The NHS is working flat out to try and meet the Two-Week Wait and other cancer targets again. But if the Two-Week Wait is the ‘wrong’ target, then this effort is pulling the NHS in the wrong direction – which is bad for the NHS and bad for people with suspected cancer.

To address some of these issues, another option is being proposed as the main cancer diagnosis target. Known as the ‘Faster Diagnosis Standard’, the aim is that people know whether or not they have cancer within 28 days of being urgently referred for suspected cancer or following a cancer screening result that shows possible cancer.

The Faster Diagnosis Standard was first proposed in 2015 as part of the NHS Long Term Plan, but it was only introduced as a performance measure in October 2021.

Although Trusts are now being measured against it, the Faster Diagnosis Standard is not currently used as the main target for healthcare professionals or as the standard by which timely diagnosis is judged. We believe that making it the main target will improve and speed up diagnosis for people with cancer.

The 28-day target will allow more time for new innovative techniques to be used during diagnosis. This in turn will save time and other resources further down the line.

For example, for someone with bowel cancer symptoms, the Faecal Immunochemical Test (FIT test) is easy and reliable, and can be provided by GP practices and carried out at home. If a person has a positive result from a FIT test, it doesn’t mean they have cancer, but that they are at high risk and further tests are required. A person with a negative result has a very low risk of having cancer.

Although the results of a FIT test may take longer than two weeks, it has the power to avoid unneeded colonoscopies by only referring those who have a positive result to hospital. Those without cancer get their results back sooner, and hospitals have fewer colonoscopies to do, which frees up staff and resources.

This will help the NHS in its efforts to tackle long waiting lists. According to a recent report, more than half a million people in England are awaiting a colonoscopy, the highest number for any procedure, with many of these on a ‘hidden’ waiting list due to pandemic backlogs.

Importantly, the Faster Diagnosis Standard is more meaningful to people and NHS staff. When someone goes to their GP with possible cancer symptoms, the first step should be to determine whether they have cancer or not as soon as possible. And the current Two-Week Wait creates illogical incentives which make more work for staff, for example booking multiple appointments when one would do or sending people for outdated tests when there are better options available.

Earlier this year Yorkshire Cancer Research responded to a consultation, recommending that the Faster Diagnosis Standard replaces the Two-Week Wait as the main cancer waiting times standard for early diagnosis.

The current target is that 75% of people should get a diagnosis within 28 days. However, when the Faster Diagnosis Standard was originally proposed, the target set out in 2015 by the Independent Cancer Taskforce would have required that 95% of people receive a diagnosis within 28 days.

We believe the bar must be raised to 95% as soon as possible. During 2021/22, 73% of people in Yorkshire received a diagnosis within 28 days, so a target of 75% is not ambitious enough and will not do enough to improve standards.

If applied with a high target, the Faster Diagnostic Standard will mean a better experience for everyone who is worried about cancer symptoms, and ultimately, the fastest diagnosis possible for those who are diagnosed with cancer.