The 31 day rule : cancer games

Yesterday, a pleasant New Year’s Day lunch with David, an old friend who is an eminent oncologist. David’s wife is a psychiatrist. Mrs C is, of course, a breast radiologist and is currently the lead clinician in her breast unit. After the teenagers had disappeared the conversation turned, inevitably enough, to medicine. NHS BLOG DOCTOR readers are familiar with the Two Week Rule. When I, as a family doctor, write TWR on the top of a referral letter, I set off a cascade of consequences which are threatening to deluge my hospital colleagues.

Most of the general public will not have heard of the 31 day rule. The 31 day rule says that, once a cancer has been diagnosed, treatment must be started within 31 days. The hospital employs 31-Day rule commissars. The cancer is diagnosed. The clock starts running. The commissar gets out her clipboard. Woe betides the oncologist if treatment does not start on or before the appointed day.

Sounds reasonable, you may say. You may even say that 31 days is far too long. Why does treatment not start immediately? The answer is straightforward. For a lot of cancers, the treatment will start within a week or two. For other cancers, and breast cancer is commonly one of them, a number of staging investigations such as CTs, MRIs, bone scans, and PET scans may need to be done. We are not working in the USA or France. Not all hospitals have PET scanners. The patient may need to go elsewhere for the investigations. And all the time, the clock is running, and the 31-Day commissar is watching. A lot of thought and discussion may be needed. There are different treatment modalities, different international protocols, and all need to be discussed at the MDT meeting. The 31-Day commissar is still watching. Though not medically qualified, she at least understands the need to do “tests”.

Finally, a decision as to the best treatment option or options is made. The commissar rubs her hands. Let’s get on with it, then. Unfortunately, there is one more stage that doctors like to go through. Discussing the options with the patients. This is never more important than with a woman who has breast cancer. She will want (and has the absolute right) to have the options put before her. She may, for example, prefer wide local excision. She may prefer a mastectomy. Some women do. She may want surgical reconstruction and, if she does, she will want to discuss that in detail with the surgeon. Often the woman will say she wants a few days to think it over. To discuss it with her husband. To discuss it with her daughter. To discuss it with her family doctor.

The commissar does not like this. She does not really understand it. She will not stop the clock, but nor is she prepared to let it run over the 31 days. What is to be done? The commissariat has made a decision and issued instructions to David and Mrs C. The patient will be allowed to have a few days to think it over. Or a few months if she likes. To avoid breaking the 31 day limit, the patient must be discharged from the hospital clinic. If, as and when she decides which treatment she wants, she must return to her GP and ask him to re-refer her back to the hospital.

To the commissariat this is the perfect solution. As soon as a patient is discharged from hospital, the “event” is “deemed” to have had a “successful outcome”. A target has been hit. Points have been scored. The GP then refers her back, presumably on a second TWR basis, and that gives the hospital a luxurious 14 + 31 days to start the treatment. The work has already been done. Treatment starts promptly. Two more targets are hit. More points are scored.

Good news, comrades. Tractor production is up yet again.