Non-specific symptoms pathway - information for professionals

PLEASE NOTE: We are in phase 1 of the NSS roll out and the service is currently only open to East Grinstead GPs.

As part of the NHS long term plan an Urgent Suspected Cancer Non-specific Symptoms (NSS) service has now been launched at Queen Victoria Hospital (QVH) and will gradually be rolled out to parts of Surrey and the whole of Sussex. The NSS project is funded by Surrey & Sussex Cancer Alliances for 2 years respectively.

What is NSS?

The NSS pathway will facilitate referrals for patients with symptoms that do not fit discretely into a single urgent cancer referral pathway as defined by NG12, but who are at risk of having cancer. These patients often experience disjointed management and are at risk of late diagnosis.

Queen Victoria Hospital NHS Foundation Trust (QVH) are currently establishing a centralised NSS service to be delivered across Sussex and East Surrey. The Community Diagnostic Centre (CDC) at QVH will act as an administrative hub for this NSS pathway.

Referrals will be received from GPs across Sussex Integrated Care Board (ICB), and the population of Surrey and Sussex Healthcare NHS Trust (SaSH). Once the referral is received, the NSS Team will then coordinate patient investigations and/or diagnostic scans, within the CDCs across Sussex and East Surrey.

The aim of the NSS pathway is to expedite onward referral of patients with possible cancer and to reassure and discharge patients with no findings or benign disease. NSS pathways are classed as USC (Urgent Suspected Cancer) pathways, and consequently reportable under cancer waiting time’s performance standards. Establishing this pathway will support the national objective of 100% NSS pathway population coverage by 2024/25.

Please note, while the initial roll out of services will be restricted to referrals from GPs local to QVH, once the model is successful a sequential roll out across the designated area covered will begin.

Why is the NSS Cancer Pathway needed?

Cancer patients presenting with non-specific but concerning symptoms are often diagnosed late, leading to poor outcomes. Those with severe symptoms often present to emergency departments. The Urgent Suspected Cancer (USC) Non-specific Symptoms (NSS) service provides a better route to diagnosis for these patients. The model of care meets the standard of confirming or ruling out a cancer diagnosis within 28 days.

  • Patients with vague symptoms often bounce around the system and are at risk of late diagnosis.
  • Around 7% of patients on an NSS pathway will get a cancer diagnosis
  • Only 5-10% cancers detected through Urgent Suspected Cancer (USC) pathways1
  • Half of all cancer patients never have a red flag symptom2
  • 67% of patients with non-specific symptoms are diagnosed at a late stage (compared to 45% site specific)2
  • NSS pathways also identify serious (non-cancer) conditions that need management in primary or secondary care
  • Sussex does not have an NSS pathway, it is the only region in the country not to have one
  • 1N Jensen Br J Cancer, 2014; 2National Cancer Diagnosis Audit 2018

If you would like to get involved in the development of this pathway across Sussex and East Surrey, or for any questions about the NSS process or patient eligibility for referral, please contact the NSS Team, Queen Victoria NHS Foundation Trust via mail:

Referral Process

Core referral criteria for non-specific but concerning symptoms include:

  • Unintentional weight loss (> 5% of total body weight)
  • Non-specific abdominal symptoms (> 4 weeks duration and not suitable for site-specific referral)
  • Unexplained worsening pain (especially back pain)
  • General malaise/fatigue (with no clear cause)
  • Unexplained worsening of breathlessness (please take steps to rule out undiagnosed heart failure, IHD, thrombo-embolic disease, COPD and infection)
  • Persistently abnormal laboratory tests which are not readily explicable including:

Significantly elevated alkaline phosphatase (>2 ULN)

Raised CRP or ESR/plasma viscosity

Raised calcium

Thrombocytosis

Anaemia with negative FIT Test

  • Radiological findings suspicious for malignancy without an obvious primary site  concerning bone lesions or abnormal lymph nodes
  • Significant clinician concern for a possible cancer diagnosis (where there is no clear urgent referral pathway for example, unexplained DVT, paraneoplastic syndromes, etc.)

Filter function test

Filter function test should be completed prior to referral:

Mandatory    

  • Full Blood Count
  • ESR or CRP
  • U&E with eGFR
  • Liver function tests
  • Bone Profile
  • PSA or CA125
  • Chest X-ray (if respiratory symptoms are present and will not delay referral)
  • Urine Dipstick
  • FIT test (abdominal symptoms or anaemia)

 

How to refer

Patient referred to the service should have all primary care filter function investigations completed before referring.

Complete the online NHS e-Referral using the NSS proforma available on e-referral system (e-RS), ensuring you choose the correct clinic/hospital/service according to patient location.

The referral will be triaged and if accepted, the patient will be contacted by telephone for assessment and if suitable referred for further investigations at one of our Community Diagnostic Centres (CDC).

Once the investigations have taken place and depending on the results, the NSS team will determine a management plan with the possible outcomes outlines below:

No radiological evidence of cancer and no further investigations required:

  • Normal scan:The patient will be discharged back to GP with further advice and discharged from the NSS pathway. If symptoms persist and there is still a clinical concern for cancer, the GP can contact the NSS team advice line for further guidance.

Non-cancer related further investigation required:

  • A serious, non-cancer finding identified:The patient will either be discharged back to GP with advice or referred onto the relevant specialty if secondary care input is required.
  • Urgent/critical actionable radiology findings: pneumothorax, large aneurysm (at risk of rupture), PE etc. should be managed as per local protocol by the CDC performing and reporting on imaging.
  • Unwell admission pathway:If admission is required action should be taken following the QVH admission algorithm. Urgent admissions will be managed by the NSS team.

Cancer suspected:

  • Cancer suspected:The patient will be transferred to the relevant specialist MDT team for further investigations using the cancer waiting times agreed policy for transfer. Once accepted by the Urgent Suspected Cancer team, they are responsible for the clinical care, management and tracking of that patient. They are also responsible for any further diagnostic tests that are needed (e.g. endoscopy, radiology, histology, or molecular diagnostic testing).

After a patient has been discharged from the NSS, an outcome letter will be written to the patient and a copy sent to the GP.

 

Non-specific symptom pathway team:

Lead Clinician Lead

Dr Saoirse Dolly

Clinical Nurse Specialist 

Lisa Smith

Pathway Coordinator

Reena Rajan

 

Contact us

The non-specific symptom (NSS) team

Community Diagnostic Centre

Queen Victoria Hospital NHS Foundation Trust

Holtye Rd, East Grinstead RH19 3DZ

T:  01342 414438

E: qvh.nss-surreyandsussex@nhs.net

Monday to Friday 8.30am – 4pm (excluding Bank Holidays)

GP referral proforma

GP referral guidelines