Project Manager Mark Rawles South West Cancer Network Media Contact Jon Miller Manager South West Cancer Network

Transcription

1 December 2015 South West Cancer Network Colorectal Diagnostic Pathway Project. ACE Programme on Early Diagnosis of Cancer South West Colorectal Diagnostic Pathway Ref: Project A74 Project Manager Mark Rawles South West Cancer Network Media Contact Jon Miller Manager South West Cancer Network

2 1) Brief description of project ) Project Arrangements... 4 Objective... 4 Aims & Ambition ) South West Current Colorectal Diagnostic Pathways... 5 Summary of Findings ) Review of Current Pathways at SW Providers ) Proposed Pathway (s) following review ) Businss case for Moving to Straight to Test ) Support for referring GPs ) Information to Support Patients ) Natioanl data collection ) Summary of conclusion ) Appendix X... 12) Appendix X - Responses ) Appedix X Description Appendx X.1 - North Bristol Appendx X.2 - Royal Cornwall Hospital Trust Appendix X.3 Taunton & Somerset NHS FT ) Appendix X.4 Barts Health NHS Trust Business Case Useful tips Your symptoms : Change in your lifestyle : Your medical history Family medical history Finally, remember ) Appendix X.5 - South Devon ) Appendix X.6 North Devon Colorectal Diagnostic Service ) Appendix X.7 Yeovil District Hospital ) Appendix X.8 Contact Details ) Appendix X.9 National Data... 51

3 1) Brief description of project This project aims to demonstrate how patients with colorectal problems (including suspected cancers) can get the right first step on a diagnostic pathway within agreed timescales. The diagnosis of colorectal cancer can be made following a number of different routes. In order to diagnose colorectal cancer earlier, more people will need to go through a diagnostic pathway, so that those with cancer are diagnosed at an earlier stage. However, the signs of symptoms of early colorectal can be subtle. 31% of colorectal cancers in the South West are diagnosed following an urgent referral but as many are diagnosed following a routine GP referral (22%) or other appointment (9%). As thresholds for some form of investigation drop, the distinction between urgent and non-urgent referrals becomes harder to manage. This is more critical as colonoscopy the main first diagnostic test carries an inherent risk to the patient and pathways have been created to manage this risk. Work carried out across the South West (including significant event audits of those diagnosed following an emergency admission) indicates that the information received by providers with referrals may not be sufficient to enable the providers to select the appropriate first step resulting in a clinic appointment or flexisigmoidoscopy by default. GPs have commented that pathways are designed from the perspective of knowing the patient has cancer and have an increasing burden of disease specific (rather than symptoms group specific) protocols and forms. Both sides agree that better communication between GP and secondary care would enable the right first step to be made for patients especially for those with the subtler signs of early colorectal cancer. In addition colorectal diagnostic services are under significant pressure especially colonoscopy but also including outpatient capacity. As a consequence to these pressures and constraints a variety of pathways operate in the South West with significant potential for more effective and efficient arrangements. This project was accepted as part of the National ACE Programme. A Programme that will Accelerate, Coordinate, and Evaluate (ACE) learning to achieve the earlier diagnosis of cancer It is estimated that if England was to achieve survival rates that matched the best in Europe, then up to 10,000 cancer deaths each year could be avoided through earlier diagnosis and access to optimal treatment. Evidence is critical in driving the system wide change that is needed to achieve faster diagnosis, and save lives. The ACE Programme is an NHS England initiative supported by Cancer Research UK and Macmillan Cancer Support. Established as an early diagnosis programme that supports the NHS outcome preventing people from dying prematurely, ACE was initiated in June 2014 and is led by Sean Duffy, National Clinical Director for Cancer.

4 The Programme will run across England for approximately 2 years and incorporates around 60 projects. The prime objective is to evaluate local approaches and develop a national body of evidence that will inform cancer commissioning. Through this, proven approaches to early diagnosis will be adopted and spread at pace and scale. The ACE Programme has two broad aims, firstly, to support NHS organisations to implement best practice, helping to remove blocks to implementation, and secondly, to test more innovative ideas such as merging current referral pathways and designing new pathways for patients with vague but concerning symptoms. The ACE Programme brings together projects already underway in the NHS and broader health community under a national umbrella of support and evaluation. This will generate sound evidence and identify best practice to help drive up the quality of diagnostic pathways across the country. The first set of outputs will provide guidance for the 2016/17 commissioning round and will be available from September The clinical and economic evidence base will add further weight and direction for the 2017/18 commissioning round. If this programmatic approach proves successful, then future calls for projects may be made. 2) Project Arrangements Outputs will be shared with local partners and the ACE Programme. Objective The objective is to get rapid spread of best practice as demonstrated in North Bristol, other innovations in the South West and more broadly from across England as supported by the ACE Programme. Aims & Ambition The project aims to implement; Straight to test & one stop clinics Merging of referral routes urgent and standard pathways Create better pathways for patients with vague symptoms The ambition is to introduce straight to test pathways whereby patients are referred into hospital diagnostic services with assurance and seen in agreed timescales. This will free services to deliver more timely access to all patients with suspected colorectal disease whilst ensuring that the net waiting times for all colorectal cancer patients improves.

5 3) South West Current Colorectal Diagnostic Pathways Work has taken place to identify the range of current colorectal diagnostic pathways across the South West and share this information to support best practice. Commissioners have been engaged and supported moves within providers to work towards implementing colorectal ACE innitiatives. This has been achieved through direct contact with both commissioners and providers and also through a series of events, webinars and meetings that have been set up to facilitate this work. Eg. Commissioning the Best Cancer Pathway Event Within the South West most hospital trusts follow the colorectal diagnostic pathway that can be seen below.

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7 To further understand what was taking place within the region a structured fact find was completed by hospitals within the South West. This helped to provide clarity on the current colorectal diagnostic pathways being provided by providers. The information from these fact finds was collated and the results below give not only a specific overview of the services provided but also a flavour of the thoughts of those involved within colorectal cancer diagnostic services within the South West region. Summary of Findings 3 hospitals have direct access already for colonoscopy and a further 4 hospitals would like to move to this in the near future Issues with bowel prep, suitability and worries of perforation lead to concerns about direct access from primary care Desire to move to straight to test (STT) but need to traige nurse led seen as solution and desire to standardise its use CT colonography also desired by some but seen as more complex and with more capacity constraints Discussion of smoothing waits between 2 ww and routine, to be lower overall. This was seen as posible but difficult with current cancer waits rules. The proposed 28 day standard from referral to diagnosis 1 should address some of these concerns. Some routine patients are getting faster access to colonosocy as they do not need to have an outpatient appointment which is scheduled merely to meet the 2 week wait standard. The South West Cancer Access Policy has been revised to allow nurse triage to be allowed as count as a 2 week wait appointment thus both speeding up the pathway and avoiding an outpatient appointment. Version 9 of the Cancer Waiting Time Guidance does not allow this and will require further local consideration. Advice & Guidnace written would be good in some circumstances See Appendix X for responses 4) Review of Current Pathways at SW Providers Curent pathways at provders were reviewed although following the start of the project a number of provders have made changes to elements of their pathways The following information gives further insight into the current colorectal diagnostic pathways provided by providers across the South West. The environment is continually changing and multiple factors affect the pressure on diagnostic services. Factors such as lowering the threshold for suspected cancer by NICE guidance can affect the number of patients being 1 Achieving world-class cancer outcomes: a strategy for England (section 5.2.7)

8 referred by primary care to endoscopy services. The potential capacity of these services needs to be managed to ensure that they can meet this demand. Commissioners need to ensure that there is sufficient capacity within the system to meet this demand. Provider Type of Pathway Additional Comments NBT STT using ICE booking system Undergoing Evaluation RCHT Nurse led OPA Patients seen in Nurse led OPC within 72 hours of 2WW referral MPH TAC Model TAC Service for urgent and non urgent patients currently being evaluated PH Standard Keen to move to STT for most 2WW SD Standard Working towards removing OPA and working towards triaged STT YH Standard Considering STT WH Standard Considering STT and moving to Pan BNSSG STT colorectal service UHB Standard Considering STT and moving to Pan BNSSG STT colorectal service RUH Standard Considering streamlining Pathway CGH NDH RDE Salisbury Standard Standard Standard Standard OPA Outpatient appoitnment STT- Straight to Test TAC Telephone Assessment Clinic BNSSG Bristol North Somerset South Gloucestershire A further series of questions were asked of providers to clarify specific aspects of the colorectal diagnostic pathway. The results by provider are listed in Appendix X. This demonstrated a variety of approaches in terms of steps but similar objectives. Sharing the pathways and experiences across the SW will facilaite other providers to adopt new models which may be more convenient for the patient, faster pathways and or less cost Assessment of patient fitness to undergo test takes place in a variety of ways already but some use this to facilitate straight to test.this is valuable learning that will support others to move to adopt similar models Most patients get results on day of test, although some providers still use a OP Follow up. Again sharing the practice may facilitate these providers exploring this option (quicker into the pathway for the patient, a faster pathway and less cost). All categorise patients for urgency All providers book the next appointment for those with a suspected cancer at endoscopy although some go via the MDT first.

9 5) Proposed Pathway(s) following review 6) Business case for Moving to Straight to Test Moving straight to test will remove an outpatient appointment from the pathway, reducing both cost and time to test. However, as the programme has demonstrated, there are compelling clinical reasons to ensure patients are properly assessed and bowel prepartion clearly explained to ensure patient safety and quality. Investing in this triage process is neccessary to facilitate this change in practice. Nurse led triage is a popular option. The Whipps Cross business cases (Appendix X) estimates the saving per patient would be 105. Calcualtions are below and exclude market forces factor. First Outpatient costs 2014/15 tariff 1 st appt 2014/15 tariff Follow up appt Proportion of patients 2 Colorectal Surgery % Gastroenterology % 2 Information in the Whipps Business case may indicate that the proportion may be the other way around which would give an average patient cost of 165.

10 Average Patient cost Nurse led triage - staff costs Band 6 nurse mid point 330,057 Band 3 administator mid point 17,972 Total 48,029 Numhbr of patients 1,855 Cost per patient 26 Whipps Cross also proposed removing follow-up appointments to communicate results for 85% of patients. This would give a further reduction of 66 per patient ( 77 x 85%). The Network will review practice in the South West if local providers are routinely using post endoscopy appointments to communicate results. This saving to the NHS as a whole of course represents a loss of income to providers. However, given the growth in both cancers and referrals for suspected cancer, it is likely that providers can reasonably easily redirect staff capacity freed by outpatient appointment changes in this way, to other activities. Challenges Loss of income for Trust. This saving to the NHS as a whole of course represents a loss of income to providers. However, given the growth in both cancers and referrals for suspected cancer it is likely that providers can reasonably easily redirect staff capacity freed by outpatient changes in this way to other activities Some investment is required to enable this change to happen. Ensuring all referring GPs are aware of the revised pathway. Anticipated benefits: Reduce the time to diagnosis and hence time to treatment. Improve the patient experience: with fewer visits and faster diagnosis. The capacity gained by the freeing up of consultants from the first outpatient appointment and reduction of potential follow-up consultations would enable the transfer of consultants to other activity. This is important with the anticipated increase in colonoscopy over the next 5 years. Meet health economy and potential commissioning needs by reduction in spend. Introduction of agreed clinical criteria to enable GPs to arrange straight to test via possible nurse triage for patients requiring a diagnostic test. Embed accessibility of lower GI endoscopic procedures in primary care. Improve the efficiency / productivity of existing trust resources e.g. reduction in outpatient clinics.

11 Impact on Waits The impact on waits can be seen in detail in Appendices X Cornwall have reduced their pathway by an estimated 10 days by changing to a nurse led OP appointment within 72 hours of GP referral. Somerset have solved the challenge of their non urgent patients being sent to a diagnostic test in a more timely manner than their urgently referred patients. This was achieved by removing the OPA for urgent referrals and implementing a nurse led telephone assessment clinic for both their urgent and non urgent referrals from primary care. South Devon are considering reducing the time spent by patients within their pathway by removing the initial OPA reducing the pathway time by up to 13 days. North Bristol have reduced their mean time to treatment by implementing a STT booking service that is designed to reduce the time patients take to have diagnostic tests and be diagnosed. 7) Support for referring GPs It is down to each individual locality to provide support and information to primary care on how to refer into the local colorectal diagnostic pathway. A good example is the education provided by North Bristol to local GPs that can refer STT via the ICE booking system. Please see appendix X for a complete breakdown of this process. Although this was written and made available to primary care clinicians from the trust the process was supported and marketed by local commissioners, the CSU and the wider healthcare community. 8) Information to Support Patients Patients having access to appropriate information at the right time is critical to any service. It can help to ensure that patients understand the next step and can give them confidence, improving their own experience. In simple terms it can ensure that patients arrive on time at the correct location and are properly prepared. A good example of information that is provided to support patients in the colorectal diagnostic pathway can be found in appendix X Colorectal telephone assessment clinic letter contained within the Barts Health NHS Trust business case. For further information on patient information please look at the tool from NHS Institute for Innovation and Improvement on the following link. d_service_improvement_tools/patient_information.html

12 9) National data collection Access to accurate timely data at this time is somewhat challenging. Due to changes in NHS organisational structure within Public Health, CSU s and the health and social care information centre has meant that it can be difficult to access specific locality based cancer data at a national level in a timely fashion. For data at trust or hospital level please contact the local organisation concerned. Where changes have been made to the colorectal diagnostic pathways within South West providers it has been very recent. These providers are currently evaluating changes and outcomes in the areas of quality, patient experience and waiting times. Information will be fed in as it is received and evaluation of services is ongoing. To provide a full evaluation of the colorectal diagnostic pathway research has taken place at a national level to assess what data would be required to asssess the impact of change. Please see tables in appendix X Possible generic data request- colorectal cancer pathways Tables have been drafted by the Policy Research Units to identify metrics, which, if collected, they believe will provide a good basis for evaluation and provide information with which to measure the impact of intervention and change to a service. Whilst it may be possible to evaluate the process if information is provided at total level e.g. the total number of tests performed during a time period before and after the intervention by a Trust, a more detailed evaluation will be possible if this data is supplied at individual (anonymised) level for which an excel template has been prepared (see template in appendix X) The advantage of this service evaluation audit approach is that ethics approval is not required as the PRU will not receive patient identifiable data. In addition to these metrics, there is also a need to collect other information for example, logistical information including costs detailing the process that your project followed to put the intervention in place. The provision of how to guides will be an important output from ACE as without this even where evaluation data shows beneficial impact it may be difficult for other areas to adopt and spread good practice. Work is on going in this area and for further information please contact James Perry ACE colorectal data lead We are concluding at this point but will advise when the national dataset is finalised and the process agreed

13 10) Summary of conclusion Most providers within the South West are considering the move towards a straight to test process within their colorectal diagnostic pathway. This is supported nationally by the ACE initiative. Some providers within the South West have already made this step and the evaluation of this change to their service is currently taking place. However with the work that has already been completed in this area, commissioners should be able to feel confident that they can support this straight to test process with the built in patients safety approaches demonstrated across the South West. This will streamline the current colorectal diagnostic pathways within South West providers. The result of this move to STT should have an impact on waiting times and ultimately reduce the mean time to treatment for those affected by colorectal cancer within the South West whilst reducing cost and improving patient experience.

14 11) Appendix X Responses Provider Q# Question Flexi-sigmoidoscopy Colonoscopy NBT 1 NDH 1 PH 1 RDE 1 SDH 1 UHB 1 WAH 1 How are the results conveyed to the referring GP? How are the results conveyed to the referring GP? How are the results conveyed to the referring GP? How are the results conveyed to the referring GP? How are the results conveyed to the referring GP? How are the results conveyed to the referring GP? How are the results conveyed to the referring GP? faxed if cancer on the day, otherwise through a letter Via fax within 24 hours Sent report on day on same day Copy of report is sent to GP A copy of the Endoscopy report is sent to the GP Clinic letter, when applicable Endoscopy report sent to GP. Also letter sent with any results of biopsies etc faxed if cancer on the day, otherwise through a letter Via fax within 24 hours Sent report on day on same day Copy of report is sent to GP A copy of the Endoscopy report is sent to the GP Clinic letter, when applicable Endoscopy report sent to GP. Also letter sent with any results of biopsies etc NBT 2 How is the patient assessed for fitness to undergo the test? GP, as part of the ICE referral. Validated through nurse led preassessment GP, as part of the ICE referral. Validated through nurse led preassessment NDH 2 How is the patient assessed for fitness to undergo the test? Either at OP review or assessment within endoscopy Either at OP review or assessment within endoscopy PH 2 How is the patient assessed for fitness to undergo the test? Telephone assessment or face to face with trained nurse depending on medical history. Telephone assessment or face to face with trained nurse depending on medical history.

15 RDE 2 SDH 2 UHB 2 WAH 2 NBT 3 NDH 3 PH 3 RDE 3 SDH 3 UHB 3 How is the patient assessed for fitness to undergo the test? How is the patient assessed for fitness to undergo the test? How is the patient assessed for fitness to undergo the test? How is the patient assessed for fitness to undergo the test? How are the results conveyed to the patient? How are the results conveyed to the patient? How are the results conveyed to the patient? How are the results conveyed to the patient? How are the results conveyed to the patient? How are the results conveyed to the patient? Pre-assessment Face-to-face or telephone preassessment. OPA On referral all relevant information is completed by doctors. Patient assessed and given information at clinic. Patient able to contact Endoscopy unit if any queries. Also on day nurse checks in person at the time of the test Follow up OP appointment Verbally on day of test plus report if non cancer Given at the time of the procedure and results discussed A copy of the Endoscopy report is given to the patient on the day. OPA following week when applicable Pre-assessment Face-to-face or telephone preassessment. OPA (moving to algorithm based referral) On referral all relevant information is completed by doctors. Patient assessed and given information at clinic.telephone nurse pre-op. Bloods reviewed to assess fit for bowel prep. Medications also reviewed as may have to stop medication. Also on day nurse check in person at the time of the test Follow up OP appointment Verbally on day of test plus report if non cancer Given at the time of the procedure and results discussed A copy of the Endoscopy report is given to the patient on the day. OPA following week when applicable WAH 3 How are the results conveyed to the patient? Face to face either on day or in further clinic. If no clinic appointment necessary then letter should be sent to patients Face to face either on day or in further clinic. If no clinic appointment necessary then letter should be sent to patients NBT 4 Are patients categorised for urgency

16 NDH 4 PH 4 RDE 4 SDH 4 UHB 4 WAH 4 NBT 5 NDH 5 PH 5 RDE 5 SDH 5 UHB 5 WAH 5 Are patients categorised for urgency Are patients categorised for urgency Are patients categorised for urgency Are patients categorised for urgency Are patients categorised for urgency Are patients categorised for urgency If cancer is suspected at endoscopy does the hospital book the next appointment If cancer is suspected at endoscopy does the hospital book the next appointment If cancer is suspected at endoscopy does the hospital book the next appointment If cancer is suspected at endoscopy does the hospital book the next appointment If cancer is suspected at endoscopy does the hospital book the next appointment If cancer is suspected at endoscopy does the hospital book the next appointment If cancer is suspected at endoscopy does the hospital book the next appointment No - patient added to MDT, appointments can be booked at Endoscopy reception No - patient added to MDT, appointments can be booked at Endoscopy reception

17 Provider Category Test Available to hospital team Available via Direct Access to GP* Current wait time to hospital team Current wait time to GP Current test reporting time Pathology reporting time Estimated date to have 2 week access to GP Brief description of issues with implement NICE Guidance for this pathway NBT Endoscopy Colonoscopy NDH Endoscopy Colonoscopy (Anaemia pt's) 2 wks Same day 5 days 6 months + PH Endoscopy Colonoscopy No 2 wks 2 wks Same day 10 days N/K Capacity RDE Endoscopy Colonoscopy No but straight to test (+triage) 2 wks 2 wks Same day 10 days Now (straight to test rather than direct) Vetting by consultant will need to continue RUH Endoscopy Colonoscopy No SDH Endoscopy Colonoscopy No 2 wks N/A Same day 1 wk Not known Plan to implement straight to test with triage Som ISTC Endoscopy Colonoscopy TS Endoscopy Colonoscopy No UHB Endoscopy Colonoscopy No 2WW 2wks 5 days Dec-15 WAH Endoscopy Colonoscopy No 2 wks 2 wks 2 weeks 2 wks Plan to introduce in late Patients will be treated as 2WW referrals and recorded and reported as such Possible capacity issues if demands increase YDH Endoscopy Colonoscopy No NBT NDH PH RDE RUH Endoscopy Endoscopy Endoscopy Endoscopy Endoscopy Flexi sigmoidoscopy Flexi sigmoidoscopy Flexi sigmoidoscopy Flexi sigmoidoscopy Flexi sigmoidoscopy 9 days Same day 5 days N/A No 2 wks 2 wks Same day 10 days N/K Capacity No but straight to test (+triage) No 2 wks 2 wks Same day 10 days Now (straight to test rather than direct) Vetting by consultant will need to continue SDH Endoscopy Flexi sigmoidoscopy No 2 wks N/A Same day 1 wk Not known Plan to implement straight to test with triage

18 Som ISTC TS Endoscopy Endoscopy Flexi sigmoidoscopy Flexi sigmoidoscopy No 6 wks UHB Endoscopy Flexi sigmoidoscopy No 2WW 2wks N/A 5 days No plans Need to review this with the team WAH Endoscopy Flexi sigmoidoscopy No 2 wks 2 wks 2 weeks 2 wks Possible capacity issues if demands increase YDH Endoscopy Flexi sigmoidoscopy No RUH Imaging CT Colonography n/a RDE Imaging CT Colonography No 1 wk N/A 1 day N/A currently we do not accept direct GP referrals for cancer patients Potential volume of referrals that have not been "triaged" and have to be seen within 7 days. PH Imaging CT Colonography 1 wk U - 6 days R - 2 wks 4 days n/a Not known Capacity SDH Imaging CT Colonography No 2WW - 2 wks U - 4 wks R - 6 wks 2WW - 2 wks U - 4 wks R - 6 wks 2 days n/a Not known not expected to increase workload as imaging done in different place on pathway but may cause spike in referrals Som ISTC Imaging CT Colonography n/a TS Imaging CT Colonography n/a UHB Imaging CT Colonography No 2WW 10 days 7 days Dec-15 Plan to introduce in late Patients will be treated as 2WW referrals and recorded and reported as such WAH Imaging CT Colonography No 2 wks N/A 2 wks Not known NDH Imaging CT Colonography - through RD&E capacity and staffing No 1 wk 16 days Same day n/a 6 months + Capacity YDH Imaging CT Colonography n/a

19 12) Appedix X Description Additional Colorectal Diagnostic Pathway information has been provided by providers to support and share best practice. Appendx X.1 - North Bristol North Bristol NHS Trust have implemented a straight to test STT service so that GPs within this locality can refer directly to colorectal diagnostic services within NBT for urgent referral. This information below explains how this works via the ICE booking system. GP Presentation guide to using title and ICE subject to make a colorectal two week wait referral Dec 14

20 2WW Symptoms and diagnostic criteria Rectal bleeding with CIBH to looser stool >6 weeks age >60 AGE TEST CIBH to loose/more frequent stools without rectal bleeding >6 weeks age > colonoscopy Iron Deficiency anaemia OGD and CTC >85 CT with extended oral prep Rectal bleeding without anal symptoms >6 weeks aged 60 or > Flexible sigmoidoscopy with PO4 enema Abdominal or rectal mass Clinic Presentation title and subject After selecting your patient then you start by selecting a new request

21 The book icon will take you to a copy of the guidance on which Presentation title and diagnostic subject test to pick These tests are all for colorectal pathways and cant be used for non colorectal 2ww referrals Click on the relevant test that you want to order, and then it will bring up a text box The system will ask you a series of questions to validate the request. This is a requirement of Presentation title and the subject endoscopy accreditation (JAG) and will help the endoscopy unit to plan for the necessary scope

22 The system requires you to make a selection. Therefore if the patient doesn t have Presentation title and any subject of these contraindications then you need to clink None of the above Each box asks you the same questions that are included within the current 2WW form. Therefore it is asking for you to confirm the Presentation title and subject symptoms. It will go on to ask you a small number of extra questions. If the answer is outside of the scope of the pathway then it will inform you that the patient is not suitable and recommend another test.

23 It is important to note that colonoscopies and CTCs need patients to have bowel prep. Therefore you are required to confirm that Presentation title and subject the patient is medically fit to receive the bowel prep. NBT will then dispense the prep to the patients. Based on your answer to this question then the system will recommend the suitable bowel prep for the patients to be Presentation title and subject dispensed by NBT

24 Presentation title and This page subject and the following three are series of questions that are key to help endoscopy effectively plan that patients scope. Please answer as fully as possible Presentation title and aiming subject for 24. If the NBT will arrange for the test to take place within two weeks of you clicking continue with request The trust will contact you with the outcome of the diagnostic within 48 hours of it being conducted, but is patient has an abnormality then NBT will pick up the care. If not then you will be provided with advice and guidance with the patient discharged back to your care.

25 The evaluation of North Bristol STT colorectal diagnostic pathway including data evaluation will be available shortly from North Bristol NHS Trust. Please contact Catherine Carpenter-Clawson Cancer Services Manager for further information.

26 Appendx X.2 - Royal Cornwall Hospital Trust RCHT have reconfigured their service so that urgent referrals are now seen within 72 hours of referral at RCHT Truro in a nurse led outpatient clinic. An overview of this service follows

27 2ww Facts and Figures patients seen Cancers diagnosed 145 (8%) Number of patients sent for: Endoscopy 440 (24.3%) Radiology 397 (21.9%) Both endoscopy and radiology 142 (7.8%) DNA clinic 15 (0.8%) Sent directly to see consultant 15 (0.8%) Admitted to hospital 6 (0.3%) Removed from the 2ww pathway in clinic 73 (4%)

28 Appendix X.3 Taunton & Somerset NHS FT The Taunton service has been reconfigured. Now both urgent and non urgent patients enter the colorectal diagnostic pathway via a telephone assessment clinic TAC service. This has been facilitated and supported at both CCG and primary care and by the wider healthcare community resulting in a more efficient and equitable service. The model was based on the original Harriet Watson Dorchester model that has now been implemented within the London Cancer Alliance. The following information gives an overview of the service. The business case for London Cancer that has also supported the introduction of the TAC service is also included.

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34 13) Appendix X.4 Barts Health NHS Trust Business Case Proposal Internal Business Case Proposal to agree a revised acute clinical pathway for patients requiring lower GI Investigations Aims To re-design the pathways for patients requiring GI investigations. Reduce the delay from referral to diagnosis Provide patients and their GPs with a definitive diagnosis for the cause of their new onset colorectal symptoms Minimise the number of appointments required Making efficient use of medical and surgical gastroenterology resources Maintain a quality and financially viable service for patients across NHS NELC & NHS West Essex Protect PbR income for Barts Health NHS Trust (BHT) Code & record activity appropriately (out-patient appointments and procedures) Background Currently, patients presenting to GPs with symptoms requiring GI investigation are referred to Whipps Cross University Hospital (WXUH) for a 1 st appointment for a Consultation (Gastroenterology or General Surgery). Patients requiring gastroscopy, colonoscopy, or flexible sigmoidoscopy are subsequently booked for the appropriate procedure and a follow up appointment (3 attendances). The proposed revised pathway is based on numerous successful examples around the country which endeavour to achieve the most appropriate first hospital appointment with the highest chance of making a definitive diagnosis. The redesigned pathway would also reduce the delay from referral to discharge or diagnosis, by minimising the number of appointments required and making most efficient use of the diagnostic resource. Following the straight to test procedure, a proportion of patients will be discharged with information to assist in self care. GPs will have information about primary care management of common benign conditions. For patients identified with bowel cancer, polyps not suitable to be excised at colonoscopy or inflammatory bowel disease, a first appointment will be made in a Consultant out-patient clinic, thus achieving a reduction in the new to follow-up ratio. Challenges and anticipated results This business case sets out the aims, challenges and anticipated results of introducing the revised clinical pathway. Challenges Loss of income for BHT (reduction of PbR out-patient follow-up activity) Investment required Ensuring all referring GPs are aware of the revised pathway Anticipated results:

35 Reduce the time to diagnosis essential when 25% of colorectal cancers are diagnosed on the routine non 2WW pathway Improve the patient experience: 2 visits, not 3 for 85% of affected patients Meet the needs of the local health economy / commissioners (value for money): 450k saving Introduction of agreed clinical criteria to enable GPs to arrange straight to test for patients requiring a diagnostic test Embed accessibility of lower GI endoscopic procedures in primary care WXUH identified as the preferred provider for this pathway/protect & increase this elective activity Improve the efficiency/productivity of existing WXUH resources: release clinic time / reduction of additional clinics Reduced follow-up ratio Help secure the outpatient reduction in medical and surgical clinics required by the commissioners The capacity gained by the reduction of follow-up consultations would enable the transfer of the resource (Consultants) to enhance productivity. This is important with the anticipated 100% increase in colonoscopy anticipated by the DoH over the next 5 years Increased awareness and usage of the pathway across by GP Clinical Commissioning Groups within NHS NELC & NHS West Essex as a result of the savings the re-design would achieve for Clinical Commissioning Groups To secure agreement of the commissioners (NHS NELC and NHS West Essex) to fully fund activity associated with the revised pathways via the Acute Contract. Current Pathway Activity/ Funding: Procedure activity (elective primary procedure) April March 2012 % Gastro % Gen Surg Colonoscopy 856 Gastroscopy 498 Flexi Sigmoidoscopy 501 Total 1,855 22% 78% First & Follow up appointments estimated activity based on 11/12 Procedure activity Speciality Activity 12/13 Tariff inc of MFF Total Income 1st Appt: to review and place patient on Waiting list Gastroenterology 1, ,114 Colorectal/General ,455 Surgery Total 1, ,569 Fup: Min. 1 per patient to explain results Gastroenterology 1, ,700 Colorectal/General ,368 Surgery Total 1, ,068

36 Minimum Total Outpatient Activity 747,637 (Estimated 85% of patients are diagnosed with Polyps or other benign conditions) The current pathways of one first attendance and 1 FUP appointment would total: 1 st and follow up appointment via Gastroenterology: 418 (inc MFF) per patient exclusive of procedure 1 st and follow up appointment via General Surgery: 350 (inc MFF) per patient exclusive of procedure Proposed Revised Pathway (Appendix 1) The revised pathway aspires to a straight to test model to achieve the most appropriate first hospital appointment with the highest chance of making a definitive diagnosis Gastroenterology Procedure (colonoscopy, gastroscopy or flexi sigmoidoscopy) Total (2 attendances) variable Colorectal/General Surgery Total 2 attendances Procedure (colonoscopy, gastroscopy or flexi sigmoidoscopy) variable First attendance x (inc MFF) First attendance x (inc MFF) fee for procedure per patient fee for procedure per patient Patients diagnosed with Cancer or Inflammatory Bowel Disease will be appointed for a first consultation and subsequent follow-up appointments (approx 15%). 85% of patients diagnosed with polyps or other benign conditions would be discharged following 1 x 1 st attendance to the care of their GP. Patients with adenomatous polyps will be entered into polyp surveillance by the endoscopy unit in accordance with British Society of Gastroenterology guidelines. Reduction in Fups (85% do not require a fup) Est Activity: FYE 12/13 Tariff Fee incl of MFF FYE PBR income loss Gastroenterology 1, ,124 Colorectal/General Surgery ,417 Total 1, ,541 Based on 11/12 colonoscopy, gastroscopy, flexible sigmoidoscopy activity levels, the revised pathway, would under PBR result in an estimated loss of income (PbR Tariff) of 470.5k for follow-up appointments, (saving to the commissioners / income loss for the Trust). However, as there is a cash envelope for 2012/2012, income will not be affected. The trust would also incur additional costs for the recruitment of staff resources initially (1 x WTE Band 6 Nurse and a 1x Pathway Co-ordinator) & equipment (dedicated phone line & computer).

37 Meeting the QIPP Target 2012/13 This will meet the QIPP target for Gastroenterology follow ups, and nearly meet the Colorectal/General Surgery follow up target, dependant on date of implementation. Releasing time & resources The introduction of the re-designed pathway should release 4 clinics per month (based on 14 patients per clinic) for colorectal/general surgery and 1 clinic per month for gastroenterology. This time could be reutilised by the dept for additional Endoscopy slots 4 lists per month performing 30 patients per month Staffing Resource This summary business case does not propose a reduction in staffing or resources in the department. Investment required Initial introduction of the re-designed pathway (Appendix 1) 1 x WTE Band 6 Specialist Nurse (insert cost) 1 x WTE Pathway Co-ordinator (insert cost) Dedicated number & telephone (insert cost) Computer (insert cost) Paper Ink cartridges (for existing printer) As the pathway develops and in anticipation of additional activity (Appendix 2): 1 x WTE Band 6 Specialist Nurse (insert cost) 1 x WTE Band 3 Administrator (insert cost) Evaluation The revised pathway will be evaluated and a report presented to the Whipps Cross Senior Site and Performance Meeting 6 months following implementation to include the following elements: A reduction in time spent on pathway until a definitive diagnosis is made The capacity released due to the revised pathways is enabling the team to improve productivity Data to evidence GP uptake of arranging straight to test procedure Service to undertake a patient satisfaction survey and analyse results Service to undertake a GP satisfaction survey and analysis the results The triage criteria will be continually audited. All patients and outcomes will be kept on a database for this purpose

38 Scope of the change Straight to Test for the following procedures only: Gastroscopy, Colonoscopy and Flexible Sigmoidoscopy, on the Whipps Cross University Hospital site. GP Education Barts Health Trust will take responsibility to promote the redesigned pathway to GP Clinical Commissioning Groups and Locality Groups in Waltham Forest, Redbridge and West Essex. Consultants will work to proactively triage referral forms completed by GPs. Any incomplete forms will be returned to the referring GP and reason stated. Referrals via agreed clinical template To be faxed (to a safe haven fax) or preferably ed to Whipps Cross University Hospital via a dedicated nhs.net account. Patients will be assigned a choose and book appointment for a telephone triage appointment. Telephone triage will be carried out by an experienced nurse to agreed criteria. The patient will be appointed for the relevant procedure and an assessment made by the endoscopist as to whether further follow up is required. All patients diagnosed with cancer or inflammatory bowel disease will be appointed for a 1 st appointment and subsequent follow up appointments. It is anticipated that a proportion of patients will be discharged after their endoscopic procedure. Marketing Opportunity The Trust would be an early adopter of the recommendations of London Cancer and the London Early detection Implementation Group. Straight to procedure pathway for colonoscopy, gastroscopy or flexible sigmoidoscopy is likely to appeal to other commissioners. Subject to sufficient resource / capacity, the revised pathway may provide a marketing opportunity. Recommendation For the re-designed clinical pathway to be agreed and implemented in two stages an initial pilot in six of our highest referring practices followed by roll out to the entire region. Next Steps Capital & Revenue funding to be made available to implement the re-designed pathway in two stages Staff to be recruited and trained Go live date to be agreed with commissioners (NHS ONEL is aware of work in progress to re-design the clinical pathway)

39 Financial Schedule Colorectal Service Patient Information Leaflet COLORECTAL TELEPHONE ASSESMENT CLINIC A guide to what will happen now that your doctor has referred you to the Specialist Colorectal (bowel) Team If there are words that you don t understand please look at the back of this leaflet where we have tried to explain them Have you got bowel symptoms? Your doctor (GP) believes that you may have a problem with your bowels and has referred you to the hospital to have some test or see a bowel specialist. We know that bowels are an embarrassing subject and no one likes to discuss them. But the specialist bowel team at the hospital, known as the

40 Colorectal Team are very used to this subject. Try not to feel embarrassed or uncomfortable about discussing your symptoms or asking them questions. This booklet contains some of the questions you might have about your referral for bowel problems. It will also explain what to expect when you are contacted by us and following this when you attend the hospital for your tests / appointments. What will happen now? Your doctor has referred you to the Colorectal Telephone Assessment Clinic. When your GP booked you in for this appointment you will have been asked to supply a telephone number (mobile or landline). You will then be sent a letter by the Choose & Book team confirming a date and time for a TELEPHONE ASSESSMENT APPOINTMENT. A Colorectal Specialist will call you on the number that you supplied at the specified date and time. PLEASE ENSURE THAT YOU ARE AVAILABLE AND FREE TO TALK AT THE TIME OF THIS PHONE CALL. YOU DO NOT NEED TO ATTEND THE HOSPITAL FOR THIS TELEPHONE APPOINTMENT. During this telephone call you will be asked questions about your health, your symptoms and your personal circumstances and advised what test you need to have. You will then be sent an appointment for this test. At present we are unable to give you the date and time of the test at this telephone appointment but we will be able to give you an indication of how long you will have to wait. What test am I likely to need? Different tests give us different information about you and your bowels. The most common tests that the bowel team use are: Flexible Sigmoidoscopy Colonoscopy CT scan MRI scan Ultra sound scan Descriptions of these different tests are listed in the glossary at the back of this booklet. You are likely to be referred straight for one of these tests. In some cases however we may ask you to come in to the out-patient department first to see the specialist. The relevant department, where the tests are carried out, will send you detailed information about the test you need, including the risks and benefits, with your appointment letter. What if I choose not to have the tests that are recommended? You will have an opportunity to discuss this with the Colorectal Specialist at your telephone assessment appointment. If following this you do not feel you want to proceed with the tests that we recommend you should discuss this with your GP that you referred you to us? What happens after I have had my investigation or test? There will be 3 possible scenarios that could occur after you have had your test.

41 1.) In some cases we will be able to tell you there and then what we think has been causing your symptoms and offer you treatment straight away or refer you on for treatment. 2.) For some people we may need to refer you on for further tests if we have not found the cause of your symptoms. This could include blood tests or further x-rays, endoscopy tests or scans (see glossary). 3.) If the test you had was carried out in the x-ray department you will be contacted either by telephone or letter by the bowel team about the results and a follow up plan. Please contact us if you have not heard anything within a few weeks of your test. Useful tips It is helpful to the specialist for you to think about your symptoms carefully before your telephone assessment. You may find the following guide helpful. Your symptoms :- What has been happening with your bowels? How long have the symptoms been going on? Are they continuous or do they come and go? Is there a pattern? eg., same time of day, before or after meals etc., Change in your lifestyle :- Have you changed your diet or exercise? Have you recently felt stressed? Have you been overseas lately? Have your friends, family or colleagues had similar problems? Are you on any new medication? Your medical history Have you had any bowel or digestive problems in the past? Have you had any operations? Do you have any cardiac (heart) past medical history? Do you take any blood thinning medicines? Are you diabetic? If so do you take tablets or insulin? Family medical history Have any of your family members had cancer, especially bowel cancer? Have any of your family members had a bowel disorder eg., Crohn s disease or Colitis? Your personal circumstances Do you live alone? How mobile are you / do you need help getting around? What support do you have around you?

42 Finally, remember Most people with bowel symptoms don t have cancer but it is important to have your symptoms checked out. The cause is usually something minor like piles or irritable bowel syndrome. If you do have piles these can possibly be treated at this appointment. If you are unsure or do not understand something you are told PLEASE ASK. We are unable to help you if we do not know your concerns. Glossary of Terms Colo- refers to the large bowel (known as the Colon) Colonoscopy a thin flexible telescope with a camera on the end that is inserted into the bowel via the back passage and the whole of the large bowel is examined. You will be sent some strong clear out powders to take the day before this test. You are given a sedative injection for this test. Computerised Axial Tomogram or CT scan a special scan where a doughnut shaped x-ray machine takes cross sectional x-ray pictures of you while you lie on a table. You will be given a special dye injection and asked to drink some special contrast fluid when you come in for this test. Flexible Sigmoidoscopy - a thin flexible telescope with a camera on the end that is inserted into the bowel via the back passage and the lower of the large bowel is examined. You will be sent some clear out tablets to take the day before this test. Magnetic Resonance Imagine or MRI scan - this involves lying in an open ended metal cylinder while detailed x-ray pictures are taken of you. Proctoscopy Examination of the back passage (anus and rectum) with a small plastic telescope. Rectal refers to the rectum (lowest part of the large bowel nearest the back passage). Ultra sound scan a scan that uses sound waves to examine your insides. Similar to the type of scan that pregnant women have.

43 Criteria for triage Anorectal Sensation of a lump/ piles/ fissure/ prolapse Obstructive defecation Bright red rectal bleeding <40 yrs Age>80 yrs Any relative bowel prep contraindication Warfarin/ clopidogrel Abdominal pain only Constipation only Diarrhoea/change in bowel habit to looser or more frequent stools Dark/ altered blood Bright red rectal bleeding >40 Previous polyps/ FHx CRC Flexible sigmoidoscopy Clinic Clinic Clinic Clinic Colonoscopy Colonoscopy Colonoscopy

44 Phone triage clinical assessment GP referral = 2WW/ non 2WW After TAC Triage = 2WW/ non 2WW Age COLORECTAL TELEPHONE ASSESMENT CLINIC DATE. Did patient go to GP in response to Media? Awareness Campaign? / No O/E (by GP) Abdo = PR = PTS. NAME AND HOSPITAL NUMBER Presenting problem: Bowels - Loose / frequent / constipation / alternating pattern / same as always How long have bowels been like this? - Rectal bleeding - yes / no If so how often Fresh or dark blood - Toilet pan / tissue / mixed with stool Anal symptoms pain on defecation, lump/prolapse, itch Abdominal pain - yes / no where? How long? Weight up / down / stable? Appetite up / down / stable? Family history of CA colon / IBD / other bowel diseases? Has your GP taken any blood tests from you recently? / No ; date Any bowel or digestive problems in the past? Have you had any previous bowel investigations? / No Any previous abdominal operations? Any problems swallowing? / No Do you have any cardiac past medical history? Any renal problems? Do you take any anti-coagulants? Are you diabetic? If so do you take tablets or insulin? Do you live alone? How mobile are you / do you need help getting around? What support do you have around you? TAC OUTCOME: List current medicines: (especially ACE-I, diuretics, NSAIDs, anti-depressants, lithium, carbamzepine, OCP) Relevant PMH :

45 Proposed new pathway Patient presents to GP With symptoms requiring lower GI Investigation GP/refers patient for telephone assessment via Choose & Book to WXUH A clinical triage assessment made by nurse in the telephone assessment clinic, patient directed to one of three options -colonoscopy -flexible sigmoidoscopy -clinic review Unable to make telephone assessmen t Colonoscopy OR flexible sigmoidoscopy Clinic Appointment CT pneumocolon Cancer Inflammatory Bowel Disease Polyps Benign diagnosis Predefined management pathway Discharge 1 st follow up appointment The evaluation of Musgrove Park Hospital colorectal diagnositc pathway change to a telephone assessment based clinic service will be available shortly. Please contact Paul Thomas Consultant Gastroenterologist for further information

46 14) Appendix X.5 - South Devon The South Devon Colorectal Diagnostic Pathway can be seen below. Work is currently taking place to streamline this pathway COLORECTAL PATHWAY SDHCFT Sept 2014 GP referral on 2ww following guidelines Other referral routes Including internal referral Direct booking Consultant triage to prerequest diagnostic tests prior to 2ww OPA Days 1-14 IDA Clinic 2WW clinic Lower GI +/- flexi sigmoidoscopy +/- biopsy Discharge or routine follow up Colonoscopy Pre-assess on day and book TCI date with Endoscopy CT CT Colonoscopy MRI for rectal patients Confirmation of diagnosis +/- histology Benign CPX testing if required Other treatments MDT Diagnosis confirmed and treatment plan made Days Diagnosis given with CNS and treatment plan agreed with patient HHR, The Lodge, LGI ca info, Local surgery info. Enhanced recovery info Treatment Options Cancer of colon Cancer of Rectum Anal cancer

47 15) Appendix X.6 North Devon Colorectal Diagnostic Service