Abstract

Introduction
Recognition of Head and neck cancer (HNC) in primary care is difficult. The HNC two-week wait referral pathway (TWW) is demanding on hospital services because of high volume of referrals with low yield of cancers. HNC specialists have developed a symptom-based risk calculator for HNCs’ referrals (ORLHC) to use as a Clinical Cancer Decision Tool (CCDT) for suspected HNC in primary care.

Aims
To identify the complexity integral to the proposed implementation of a CCDT for referral decisions about patients with signs and symptoms of HNC.

Methods
Qualitative methods were used. A Normalization Process Theory framework synthesis of the qualitative data of GPs’ experience of CCDTs was undertaken. The results of this informed a semi-structured interview study with 53 stakeholders (GPs, surgeons, and patients) to interrogate the potential and emergency pandemic implementation of ORLHC. The data were analysed using the Non-Adoption, Abandonment, Scale up, Spread, Sustainability (NASSS) framework.

Results
Six studies were identified for the framework synthesis, which showed that CCDTs were useful to increase awareness of signs and symptoms of undiagnosed cancer. Concerns centred around clinical acumen, specialists’ impression of referrals generated by a CCDT and integration within existing systems. Fifty-three interviews were conducted. Data analysis using the NASSS framework identified complexities that may impede implementation. These included (1) understanding and interpretation of symptoms of HNC, (2) how GPs employ existing CCDTs, (3) financial incentives, and (4) the impact on referral behaviour of national cancer policy priorities. Concerns about the application of ORLHC in the primary care context were identified. Opportunities exist to improve communication between primary and secondary care to triage referrals to the most appropriate clinician.

Conclusion
This rigorous assessment has shown that ORLHC in its current form does not have the evidence base, nor financial support, to justify further work exploring its implementation for use by GPs as part of their referral process.