1. Colorectal Pathway North Bristol NHS Trust

2. Background Colorectal pathway introduced in 2006 Shorten patient pathway Straight to test Reduce routes into the system

3. Reason for Change Introduction of CTC Confusion about subsequent pathways Pathway for elderly Pathway for anaemia Sub specialist clinics eg anal fissure/prolapse

4. Reasons for change Discovery programme We’re told GPs want to refer directly to test

5. Aims To change our pathway in line with NICE guidance and new innovation To offer the opportunity for GPs to book direct to test To improve patient experience To improve early cancer diagnosis

6. 2WW Symptoms Rectal bleeding with CIBH to looser stool >6 weeks age >60 AGETEST 60-75 colonoscopy 75-85 CTC >85 CT with extended oral prep CIBH to loose/more frequent stools without rectal bleeding >6 weeks age >60 Iron Deficiency anaemiaOGD Rectal bleeding without anal symptoms >6 weeks aged 60 or > Abdominal or rectal mass Flexible sigmoidoscopy with PO4 enema Clinic and

7. Referral pathway based on symptoms Pathway tells you what test to order We track the patient internally to meet cancer targets Test shows cancer/significant abnormality Test is normal or non cancer diagnosis Back to GP with advice We triage We book tests GP refers as now either to clinic via C&B or TWW referral to cancer office Option 1 Option 2 We deal with ongoing tests GP books test or clinic

8. In addition You will always have the option to send to clinic instead of to test You can choose CTC over colonoscopy if patient has weight loss as well or you have concerns that the diagnosis may be extra colonic eg ovarian

9. After selecting your patient then you start by selecting a new request

10. The book icon will take you to a copy of the guidance on which diagnostic 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

11. The system will ask you a series of questions to validate the request. This is a requirement of the endoscopy accreditation (JAG) and will help the endoscopy unit to plan for the necessary scope

12. Each box asks you the same questions that are included within the current 2WW form. Therefore it is asking for you to confirm the 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.

13. Based on your answer to this question then the system will recommend the suitable bowel prep for the patients to be dispensed by NBT

14. It is important to note that colonoscopies and CTCs need patients to have bowel prep. Therefore you are required to confirm that the patient is medically fit to receive the bowel prep. NBT will then dispense the prep to the patients.

15. This page 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

16. 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 aiming for 24. If the 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.

17. 3 month review Pathway changes for the majority of the patients Improved patient experience Shorten care pathway Has taken pressure off of CTC and clinic capacity, enabling a shorter wait for these elements of the pathway Colorectal 62 day cancer performance: JanuaryFebruaryMarch 80.8%88.9%95%

18. GP feedback “the new pathway looks fantastic…simple and understandable which is great for those of us easily bamboozled by multiple pathways from multiple departments” “Thank you…the use of ICE is also very welcome, makes the job that little bit easier and every little helps” “I have just done my first 2WW colorectal pathway referral via ICE. It is a brilliant system, very straight forward. Well done”

19. Findings so far Row LabelsJanuaryFebruaryMarchApril (until 20th)Grand Total Colitis1113 Colonic finding other than cancer152210 Colorectal Cancer2114 Inconclusive examination11 Normal examination51613438 Polyps identified & removed at endoscopy145111 Small polyps, (<6mm polyps), not removed needing therapeutic endoscopy112 Other/ outcome not yet captured452130 Grand Total734283099

20. Challenges Took 6 months to introduce pathway – cost implication for CCGs GP uptake has been slower than anticipated Rolling pathway out for all colorectal patients

21. Further information Ann.Lyons@nbt.nhs.uk – colorectal surgeonAnn.Lyons@nbt.nhs.uk Anne.pullyblank@nbt.nhs.uk – colorectal surgeonAnne.pullyblank@nbt.nhs.uk Niall.prosser2@nbt.nhs.uk – Assistant General Manager for SurgeryNiall.prosser2@nbt.nhs.uk