1. Straight to Test Colonoscopy Pilot Sas Banerjee, Matt Hanson, Aman Bhargava and Joseph Huang Consultant General & Colorectal Surgeons Noel Thin & Paul Vulliamy Surgical Registrars Victoria Harrison Surgical Services General Manager Angela Ridgeon Specialist Nurse STT Steering group 11 th April 2016

2. AIMS OF PRESENTATION Current state at BHR Pilot Outcomes Recommendations

3. WHY STT? CONCORD-2 study 2014 UK cancer survival still lags behind other European Countries Early diagnosis and early treatment around world increases cancer survival Driver: improving Colorectal Cancer survival

4. NATIONAL OPERATING STANDARDS: THE FOLLOWING STANDARDS APPLY TO ALL PATIENTS: All patients with suspected cancer who are referred urgently by their GP must be seen within 14 days of the GP decision to refer being made. All patients diagnosed with any form of cancer will receive their first treatment within 31 days of diagnosis. All patients referred through the urgent 14 day cancer referral route and subsequently diagnosed with cancer will receive their first treatment within 62 days of the date of referral.

5. INTRODUCTION: PATHWAY – REFERRAL OPTIONS Pt presents at GP with colorectal symptoms Manage the patients in Primary care Routine 18 week referral Urgent 2week wait (2WW) referral

6. CURRENT PATHWAY – STANDARD 2WW REFERRAL Outpatient appt within 14 days Sent for diagnostics Follow up appointment Refer back to GP Further diagnostics Discussed at MDT Decision to treat – with 31 days of DTA and 62 ref Refer to Oncology or other provider Discharge Prescribed medication - Treated Refer back to GP- Discharged *£138 First attendance – General Surgery function code *£84 follow up attendance – General Surgery function code *£280 for a colonoscopy or £394 for a colonoscopy with biopsy *All tariffs exclude MFF and are for demonstrative purposes 2016/17 PBR document used *£94 follow up attendance – clinical oncology function code

7. Total Number of Two-week Wait Referrals, All Cancers BHRUT Data

8. Total Number of Two-week Wait Referrals, Suspected Lower GI Cancer BHRUT Data

9. Monthly Number of Colonoscopies Resulting from 2WW Referrals, 2013-15

10. Proportion of 2WW Referrals Diagnosed with Colorectal Cancer BHRUT Data

11. Suspected colorectal cancer, p=0.10 All suspected cancers, p=0.05 Proportion of Patients Seen Within Two Weeks of Referral

12. AN ALTERNATIVE PATHWAY? – STT REFERRAL Telephone Patient Triaged STT OPA and colonoscopy on the same day within 14 days of ref Refer back to GPDiscussed at MDT Decision to treat – with 31 days of DTA and 62 ref Refer to Oncology or other provider Discharge Further investigations Follow up appointment Standard 2WW pathway *local tariff has not be agreed

13. FEASIBILITY OF STT AT BHR? STT PILOT Measures – Determine if it is pragmatically possible to co ordinate and facilitate at BHR – Determine resource +/- training needs – Determine endoscopy capacity – Staff and Patient feedback – Does it facilitate the 2WW pathway? – Cost effectiveness?

14. SET UP AND EVALUATION Trust committed to running a 2 phase STT pilot trial Phase 1: 3 week pilot in November 2015 Phase 2: 8 week pilot in January and February 2016 Specialist nurse was appointed and specific endoscopy lists ring fenced for pilot. Pilot led by SAB chairing weekly steering group meetings After Phase 1 results were reassessed and presentation made to NHS England Re-evaluation and expansion of pilot in Phase 2

15. 2WW Referral Reviewed by CNS- vetted by consultant 2WW Clinic criteria not met Phone Consultation – Nurse Led 2WW Clinic Seen by consultant; history & examination performed, + Colonoscopy + Management decision made and results and dictated letter generated Normal or minor haemorrhoids – discharge IBD- referred to Gastro as a new patient Colonoscopy unsuccessful– referred for same day CT pneumocolon Polyp surveillance Cancer – referred to MDT with staging CT scans requested

16. EXCLUSIONS AT POINT OF REFERRAL > 80 years of age Mobility problems Uncontactable by phone Language barrier Recent Colonoscopy Iron deficiency anaemia Abdominal mass Mental Health issues/memory problems/Dementia Anticoagulation Minority of patients choose clinic first

17. Referrals over 11 weeks (Nov Jan/Feb) N= 478 Appropriate STT N=115 (76%) Completed STT N=108/115 (91%) Other Investigation N=16 (15%) ( CT, CTC, OGD) Biopsies taken N=60 (55%) Excluded N=37 (24%) Offered 2WW clinic Normal/Benign condition N=87 Suspected IBD N=7 Polyps N=13 Cancer N=1 Drop outs N=7 (6%) 1 seen in OPD 2 DNA 2 Cancelled 2 Abandoned Taken off 2WW OPD FU N=27 (24%) Telephone triage N= 152 (32%)

18. COMPARATOR GROUP: CURRENT 2WW PATH In same time period – 100 pts rejected from STT, matched as a pseudo control group – 50% Males, median age 65.5 (range 24-91) Reasons for exclusion/OPD: – Over age limit: 17% – No answer to telephone triage = 30% – No available carers = 10% – Iron deficiency anaemia= 11% – Abdominal mass= 2% – Other = 30%: already had appt, request tx to another trust, unable to take time off, recent colonoscopy, not able to communicate in English

19. 2WW N=100 2WW OPA N=88 Colonoscopies completed N= 70 (95%) Other Investigation N=21 (30%) (CT, MRI scans, OGD) Biopsies taken N=38 (54%) Failed to attend N=12 (6 DNA, 6 inappropriate ) Normal/Benign condition N=56 Suspected IBD N=4 Polyps N=6 Cancer N=4 Discharged N=3 (3%) Back to ref OPD FU N=31(44%) 2WW c/scope N=74 (84%)

20. STT PILOT TIME INTERVALS 106/108 (97%) met the 2WW target, (2 breaches) – 1 did not receive prep and 1 DNA first appt Time from referral to first consultation – Median 10 days (range 6-21) Time from referral to colonoscopy – Median 10 days (range 6-21) Time from colonoscopy to biopsy result – Median 15 days (range 4-23) Time from referral to decision to take off 2WW – Median 10 days (range 6-21)

21. CURRENT PATHWAY: 2WW TIME INTERVALS No 2WW breaches Time from referral to first consultation – Median 8 days (range 3-22) Time from referral to colonoscopy – Median 26 days (range 8-92) Time from colonoscopy to biopsy result – Median 13.5 days (range 6 to 31) Time from referral to decision to take off 2WW – Median 31 days (range 4-68)

22. COMPARING PATHWAYS Fig:1Fig:2Fig:3

23. MEDIAN TIMELINE Days 12345678910111213141516171819202122232425262728293031 STT D Days 32333435363738394041424344454647484950515253545556575859606162 Days 12345678910111213141516171819202122232425262728293031 2WW D Days 32333435363738394041424344454647484950515253545556575859606162 Wait for consultation Wait for colonoscopy Wait for biopsy result

24. STT: PATIENT AND STAFF SATISFACTION In general patients and staff thought STT was quicker and more convenient for the patient

25. LEARNING ABOUT RESOURCE ALLOCATIONS: 2:1 ratio of phone calls made for one pt to have STT Time spent for each phone call was average 20 minutes Endoscopy capacity: Each STT was appointed a 2.5 standard endoscopy slot as opposed to standard colonoscopy at 2 points It was agreed that ring fenced colonoscopy lists would be used Each week 5 lists (2x SAB), (1x MH), (1x JH)and (1x AB)

26. EXAMPLE OF ENDOSCOPY UTILISATION STT ActivityDNA/Cancelled Mon 16.11.15 amList cancelled Wed 18.11.15 am3 (+1 colon +1flexi)(1 not STT) Wed 18.11.15 pm2 (+ 1 flexi)2 Mon 23.11.15 amConsultant Post Take Wed 25.11.15 am4 (+1 colon) Wed 25.11.15 pm2 (+1 colon, +1 OGD)1 Mon 30.11.15 am3 (+1 colon)1 Wed 02.12.15 am4 Wed 02.12.15 pm5 Mon 07.12.15 am1 (did not initially receive prep)

27. COST EFFECTIVENESS?

28. CLINICAL LEARNING POINTS FROM PILOT Decision making seems quicker on STT Who are the decision makers in the pathway? – Clinician in OPD vs. Endoscopists vs. Clinicians who review results – Who is responsible for ordering extra investigations to aid decision (rpt colonoscopies or CT scans) How do unexpected biopsy results effect the pathway? Only 1 cancers was found in STT pilot Who will provide service for STT – Colorectal Consultants or other Endoscopists also.

29. PROCESS LEARNING POINTS Directly the tariff for STT and 2WW will be the same By improving the speed/efficiency of treatment – breaches and therefore penalties may be avoided. Efficiency of endoscopy sessions vs that of extra clinics + endoscopy sessions may bring a cost saving benefit Is it possible pathway for all comers Consider cost of extra Specialist Nursing staff to run telephone triage clinics Consider training/education about appropriate roles of endoscopists in facilitating appropriate data capture

30. STT AT BHRUT – LOOKING AHEAD Agree tariff for Telephone Triage Clinic Offer capacity of 20 colonoscopy slots per week Aim to increase capacity and reduce the pressure on 2 week wait pathway Ensure robust audit of pathway and monitoring of satisfaction surveys Advice from London Cancer, NHS England, underpinned by numbers needed to treat, financial and clinical outcomes.

31. THANK YOU Questions ?