New Pathways to Diagnosis November 2013 Ed Seward on behalf of theDiagnostics Group Phil AndrewsColorectal Pathway London Cancer

Our remit Optimising the diagnostic pathway

The Background Colorectal cancer is a preventable disease As a country, we relatively under investigate, and have poor outcomes for colorectal cancer. These facts are probably related. Easy and timely access to diagnostics should save lives

The Background Colorectal cancer is a preventable disease As a country, we relatively under investigate, and have poor outcomes for colorectal cancer. These facts are probably related. Easy and timely access to diagnostics should save lives

Monday 26th March 2012 National Cancer Intelligence Network Press Release ‘Nearly 10% of bowel cancer patients die within a month of diagnosis’

Wednesday 11th April 2012 DoH Direct Access to Diagnostic Tests for Cancer Best Practice Referral Pathways for General Practitioners 25% of pts with CRC are diagnosed as an emergency presentation, 26% are diagnosed as a 2WW, 24% are diagnosed as a GP referral not through the 2WW pathway Suggests dropping age requiring investigation from 60 to 40 yrs Suggests open access sigmoidoscopy access +/- ‘one stop shops’

Monday 5th March 2012 DoH NHS Improvement Agency Rapid Review of Endoscopy Services Demand for endoscopy set to double over the next 5 years Emphasises the importance of organisational change to improve efficiency, data collection, service and user involvement, optimise capacity, guarantee patient care

What used to happen Consultant triage GP referral Out-patients Lower GI investigation Out-patients 8 weeks 6 weeks 3 months BUT 27% of patients diagnosed on non 2WW pathway AND 85-90% conversion rate to lower GI investigation

What will now happen Nurse telephone assessment GP referral Lower GI investigation ? Out-patient review 3 days 2-4 weeks Reduces waits in the system Reduces costs

How does it work? Nurse assessment and triage Given as a ‘choose and book’ appointment List of questions, including symptoms and any anticipated problems with bowel prep. Simple algorithm to follow Able to book in for an appointment

How does it work? Lower GI Investigation Assessed by a consultant/senior health care professional Decision made by them as to whether further input is required Database/audit ongoing

But does it work? Tried and tested Northumberland Dorchester St Marks Whittington Homerton Leeds Imperial Other areas e.g. cardiology

Pics on stick

GP referral = 2WW/ non 2WW After TAC Triage = 2WW/ non 2WW 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?

O/E (by GP) Family history of CA colon / IBD / other bowel diseases? Has your GP taken any blood tests from you recently? Yes / No ; Any bowel or digestive problems in the past? List current medicines: (especially ACE-I, diuretics, NSAIDs, anti-depressants, lithium, carbamzepine, OCP) Have you had any previous bowel investigations? Yes / No Any previous abdominal operations? Any problems swallowing? Yes / 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:

So what’s the algorithm? AnorectalFlexible sigmoidoscopy e.g. sensation of a lump/ piles/ fissure/ prolapse Bright red rectal bleeding <40 yrs DiarrhoeaColonoscopy Dark/ altered bloodColonoscopy Bright red rectal bleeding >40Colonoscopy Previous polyps/ FHx CRCColonoscopy

Our data 59 pts so far – 39 on 2WW pathway Mean age 60 yrs (34-88 yrs) Mean wait for TAC 2 days (0-6 days) 2 flexis, remainder colonoscopies Usual indication CIBH or PRB

Our data Mean total wait :2WW 8.2 days 18WW 11.6 days

Our data Endoscopic findings: 1 CRC (in 18WW) 3 IBD 9 patients with polyps (inc 1 FAP) 1 pancreatic cancer (in 2WW) Usually – diverticular disease or normal

Our data 2 DNAs (both 2WW= sent clinic appt) 8 ‘new’ clinic appts for further follow up 1 pt unable to contact by phone (=sent clinic appt)

Our data Estimated savings to commissioners 48 clinic slots x £273.5 = £13128 (but nurse salary etc) Time on pathway saving (maximum) of71% 2WW 88% 18WW

Other benefits Every patient gets pre-assessed Same diagnostic criteria applied to every patient Intense scrutiny of pathway and outcomes Huge QIPP benefit Helps massively with breaching

Our pathway Enormously popular with patients GPs love it Commissioners think it’s great Endoscopy staff cautiously welcoming

What’s next? Expand numbers Look at other areas e.g. upper GI, hepatology

Interested? Business case available Happy to share learning Speak to EVERYONE, in and out the hospital