Changing trends in the management of colorectal cancers and its impact on cancer waiting times

OBJECTIVE: The aim of this study was to compare the differences in the presentation, management and waiting times for new colorectal cancer (CRC) patients over 5 years in a single metropolitan cancer centre. METHODS: A retrospective comparative study of new patients with CRC presenting in the years 1998 and 2003. The groups were compared for referral type, Dukes' stage, site, cancer waiting times and primary treatment. RESULTS: There were 72 new patients in 1998 and 77 in 2003. In 1998 33% were seen urgently and 28% as emergencies whereas in 2003 55% of patients were seen as urgent or target wait patients and 16% as emergencies. The 2-week target for urgent referrals was met in 50% of cases in 1998 and 90% in 2003. In 2003 a higher proportion of patients received adjuvant or neoadjuvant treatment. Stage at diagnosis was similar in both groups, except stage 'D' which was 21% in 1998 and only 12% in 2003. The 31-day Cancer Waiting Time (CWT) target from decision to treat to first treatment would have been met in 81% of cases in 1998 and 79% in 2003. The 62-day overall CWT target from referral to first treatment for urgent GP referrals would have been met in 46% of cases in 1998 and 57% in 2003. CONCLUSION: More CRC patients were referred urgently in 2003. Most, but not all of these were referred as target waits. The time taken for the patient's journey did not improve between the two cohorts, possibly in part, because more complex treatments are now provided. Further work and perhaps new thinking are needed in order to achieve Cancer Waiting Time targets.     

Evolution of the two-week rule pathway – direct access colonoscopy vs outpatient appointments: one year''s experience and patient satisfaction survey

Abstract Objectives The aim of this study was to compare the effectiveness of Direct access colonoscopy (DAC) vs outpatient appointments for two-week rule colorectal cancer referrals and to evaluate the satisfaction of patients referred through these routes. Patients and methods Data were collected prospectively from January 2003 to December 2003 on patients who were referred for DAC or outpatient appointments at the discretion of the referring General practitioner via the Lower GI two-week rule pathway. A postal questionnaire was used to survey patient satisfaction. Results Six hundred and thirty-nine patients were referred via the two-week rule pathway; 188 patients underwent colonoscopy at their initial hospital visit and 19 (10.1%) colorectal cancers were diagnosed; 442 patients had an outpatient appointment and 32 (7.2%) colorectal cancers were identified. There were 7 (1%) inappropriate referrals and 2 patients refused investigations. All outcome parameters measured were reduced for patients referred directly for colonoscopy including time to definitive investigations (Median 9 vs 52 days P < 0.0001), time to histological diagnosis (Median 14 vs 42 days P < 0.0001) and time to treatment (Median 55 vs 75 days P < 0.0483). One hundred and seventy patients were surveyed by the postal questionnaire of whom 127 (75%) responded. Ninety-eight percent of patients were satisfied with the service provided. Four (6.6%) of 60 patients who had undergone direct access colonoscopy expressed a desire to be seen at the outpatient department initially. Conclusions Direct access colonoscopy results in significantly reduced times to histological diagnosis and definitive treatment in patients with colorectal cancer. Patients can be directly admitted for investigations bypassing the outpatient clinic without affecting patient satisfaction.     

The impact of national guidelines on the waiting list for colonoscopy: a quantitative clinical audit

Objective To assess the compliance of the surveillance colonoscopy waiting list with ACPGBI/BSG guidelines for colonoscopy follow‐up and to measure the impact of adjusting referrals to be inline with the guidelines. Design and Setting This is a quantitative five‐stage clinical audit cycle involving a large patient cohort from the Kent and Medway Cancer Network, which includes seven hospitals across four NHS Hospital Trusts and an estimated population of 1.8 million. Participants 3020 patients were waiting for a surveillance colonoscopy. Their notes were reviewed and the indications for colonoscopy were compared with the ACPGBI/BSG 2002 guidelines. Interventions Those patients whose referral to the surveillance colonoscopy waiting list was not found to be compliant were adjusted to be inline with the guidelines. Main outcome measures The impact of adjusting the surveillance colonoscopy waiting list on the diagnostic colonoscopy service was assessed by measuring the average waiting times for a colonoscopy before and after the intervention. Results Around 22% (n = 664) of surveillance colonoscopy referrals were inline with the guidelines, 51% (n = 1540) could be cancelled from the list and 27% (n = 816) could be given a new date. Implementing these recommendations reduced the average wait for a diagnostic colonoscopy from 76.8 to 56.0 days (P = 0.0022). Conclusion Following guidelines for surveillance colonoscopy can reduce waiting times for diagnostic colonoscopy. This allows a faster patient journey for diagnostic colonoscopy and a uniform plan for duration and frequency of surveillance colonoscopy. However, this action promoted serious debate on the social, moral and ethical issues.     

Plastic surgery outpatient audit: principles and practice of "consultant only" clinics

The effect of instituting "consultant only" clinics on plastic surgery outpatient activity was to produce a 19% reduction in both clinic sessions and new patient bookings, but a 50% reduction in booked follow-up patients; non-attender rates reduced from 20% to 11% (Northern General Hospital, April 1986-March 1989). Mean clinic attendances reduced from 35 to 26 (Northern General Hospital) and from 33 to 27 (Barnsley District Hospital)--26% and 18%, respectively. Analysis of new referrals to such clinics in the 6 months January-June 1989 showed 41% of patients came from general practitioners, although 80% of "aesthetic" conditions came from this source. 31% of referrals were for malignancy, 51/72 (70%) being basal cell carcinomas. Malignancies waited on average 4 weeks, benign conditions 15 weeks, and "aesthetic" conditions 28 weeks from referral to consultation. Such clinic management has dramatically reduced follow-up episodes, but regulation of new patient attendances is associated with appreciable waiting times for non-malignant conditions. To reduce such waiting times and pursue a "consultant only" clinic policy nationally requires many more consultants.     

'Paper Clinics'- a model for improving delivery of outpatient colorectal services.

OBJECTIVES: The overburdening of colorectal out-patient clinics necessarily leads to delays in time from referral to consultation and subsequent clinic attendance. This study aimed to ascertain the feasibility of 'paper clinic' follow-up rather than all patients receiving a routine follow-up appointment following investigation. A more efficient outpatient follow-up process should reduce unnecessary follow-up, thereby facilitating the speedy investigation and diagnosis of patients through changes in clinic profiles. METHODS: From August 2001 all patients seen in the outpatient clinic of one (part time) Consultant colorectal surgeon, who required investigation, were prospectively recorded on a 'paper clinic' form. These patients were given the necessary test request forms but were not given a further outpatient appointment. The results of the investigations were reviewed, together with the patients' medical records at a formal fortnightly 'paper clinic' session carried out by the Consultant and Nurse Consultant, and a treatment plan derived. Patients then followed one of 5 follow-up pathways and were notified in writing with a copy to their GP. RESULTS: During a 24-month period a total of 897 patients were reviewed using the 'paper clinic' follow-up system. Of these, 285 (31.8%) patients were discharged without further follow-up. In a given 3-month period when the clinic was well established, 152 patients were reviewed, of whom 27% were discharged from follow-up, 17% received SOS appointments, 13% required further investigation (and consequently were returned to 'paper clinic' follow-up), and 7% received Nurse led follow-up. In this 3-month period 64% of patients reviewed by 'paper clinic' follow-up did not return to Surgical Outpatient's and 12% received a Surgical Outpatient appointment for review. CONCLUSION: 'Paper clinic' follow-up is an effective and feasible follow-up alternative, resulting in a major decrease in outpatient follow-up burden. This has allowed the redesign of the outpatient clinic profile allowing for an increase in new urgent slots, and more rapid clinic follow up review of those patients who need it. Re-design and rationalization of existing services can result in considerable service improvement. Expanding clinics should not be considered the only option when faced with capacity and demand issues.     

Does Limiting Long-Term Follow-Up for Breast Cancer Allow All Referrals to be Seen in 2 Weeks?

INTRODUCTION

The UK National Institute for Health and Clinical Excellence (NICE) recommends that breast cancer follow-up should be limited to 2–3 years stating this will ‘release resources’ making it ‘possible for all women with breast symptoms to be seen within 2 weeks’. In 2000, breast cancer follow-up services in North Bristol were redesigned to reflect evidence-based best practice. The aim of this paper is to assess the impact of this policy on numbers of follow-ups, clinic capacity and waiting times.

PATIENTS AND METHODS

Data regarding the numbers of new and follow-up patients seen in breast clinic between January 2000 and December 2005 were collected from the hospital Patient Administration System. New patients were categorised as either ‘routine’ or ‘urgent’ according to ‘2-week wait’ rule guidelines. Median waiting times were calculated for each group and nominal appointment times assigned in an attempt to assess the effect of any changes on clinic capacity.

RESULTS

The number of follow-ups decreased by 33% as a result of the new policy. Numbers of referrals over the same period, however, increased by 14%. Routine referrals declined, but there was a 27% increase in ‘2-week wait’ patients. Waiting times for routine appointments initially decreased in response to reduced follow-up, but then rose as the number of ‘2-week wait’ referrals increased.

CONCLUSIONS

Reducing long-term follow-up is a simple and effective method of increasing clinic capacity but its effects are inadequate and transient in the face of increasing service demand. Additional innovative and creative strategies will be required if all breast patients are to be seen within 2 weeks.     

Tales from the frontline: the colorectal battle against SARS

Objective The recent worldwide epidemic of Severe Acute Respiratory Disease (SARS) caused over 800 deaths and had a major impact on the health services in affected communities. The impact of SARS on colorectal surgery, particularly service provision and training, is unknown. This paper reports these changes from a single colorectal unit at the centre of the outbreak. Patients and methods Hospital databases and electronic patient records covering the 4 months duration of the SARS epidemic and an equivalent period preceding SARS were compared. Data was collected for inpatient admissions, outpatient consultations, operative surgery, colonoscopy and waiting times for appointments or surgery. Results The SARS epidemic resulted in reductions of 52% for new outpatient attendances, 59% for review attendances, 51% for admissions, 32% for surgical procedures and 48% for colonoscopies. Major emergency procedures, cancer resections and complex major procedures were unaffected. Operative procedures by trainees reduced by 48% and procedures by specialists reduced by 21%. Patients awaiting early or urgent outpatient appointments rose by 200% with waiting times for colonoscopy increased by a median 3, 5 or 9 weeks for outpatient, inpatient or non‐urgent cases, respectively. The waiting time for minor elective colorectal surgery was extended by 5 months. Conclusion SARS resulted in a major reduction in the colorectal surgical caseload. The consequences were evidenced by a detrimental effect on waiting times and colorectal training. However, serious pathology requiring emergency or complex surgery was still possible within these constraints.     

Open‐access colonoscopy: outcomes of referrals from the emergency department

Aim The study investigated the diagnostic outcome of colonoscopy referrals from the emergency department (ED) via an open‐access system. Method  A retrospective cohort study over two years was performed on all patients under 65 years referred for open‐access colonoscopy by the ED in a hospital with an annual ED attendance of 140 000. Patient characteristics and presenting symptoms were retrieved. Waiting times from presentation to colonoscopy were recorded. Results  Over a 2‐year period, 266 patients were referred, of whom 37 defaulted, leaving 229 patients who had a colonoscopy. The mean age was 48.3 ± 11.3 (SD) and the female/male ratio was 229/125. The most frequent presenting symptoms included: rectal bleeding (n = 142, 62%), change of bowel habit (n = 47, 20.5%) and abdominal pain (n = 40, 17.5%). The median waiting time from presentation to colonoscopy was 17 (range 1–69) days. A positive colonoscopic finding was recorded in 45.4%, including colorectal cancer in 12 (5.2%). Conclusion  The rate of a positive diagnoses from the ED‐based colonoscopy referral service was comparable to that of the general Hong Kong population. This approach may help to reduce the waiting time for colonoscopy in a specialist colorectal clinic.     

Why wait for a colonoscopy? An easy cure

OBJECTIVE: Three thousand five hundred and forty-nine patients are waiting for a colonoscopy in the Kent and Medway cancer network. New guidelines identify those who require surveillance for polyp, cancer, IBD and family history. Our hypothesis was that most of the patients on the waiting list would no longer need a colonoscopy if the new guidelines were applied. PATIENTS AND METHODS: We compared the ACPGBI guidelines for screening/surveillance colonoscopy with the indications in 411 notes of one hospital's waiting list and removed patients as appropriate. In the second part of study we analysed 192 patients attending colonoscopy in seven hospitals in the region and calculated the potential impact of the guidelines on our waiting lists. RESULTS: Of 411 patients on the waiting list in one hospital, only 98 (24%) needed to remain on the list. 142 (34%) were cancelled completely. One hundred and seventy-one (42%) were taken off the 'waiting' list and rebooked for a later date since according to the new guidelines the colonoscopy was not due yet. Of 192 colonoscopies actually performed during the study period in 7 hospitals of Kent and Medway cancer network, 72 (38%) were for surveillance. Two thirds of those were not in line with the guidelines. As a result of implementing the guidelines, waiting times for diagnostic colonoscopy fell from 12 to 4 weeks for urgent, and from 40 to 15 weeks for routine referrals. CONCLUSION: A quarter of the 8000 colonoscopies performed annually in our region are unnecessary when compared to the guidelines. More than three quarters of our waiting list could be removed by reviewing the notes. Implementing the guidelines in one cancer network would save pounds 1 million per year even on conservative estimates of pounds 500 per colonoscopy. It would also reduce the waiting times for diagnostic colonoscopy.     

The One-stop trial: Does electronic referral and booking by the general practitioner (GPs) to outpatient day case surgery reduce waiting time and costs? A randomized controlled trial protocol

Background

Waiting time and costs from referral to day case outpatient surgery are at an unacceptably high level. The waiting time in Norway averages 240 days for common surgical conditions. Furthermore, in North Norway the population is scattered throughout a large geographic area, making the cost of travel to a specialist examination before surgery considerable. Electronic standardised referrals and booking of day case outpatient surgery by GPs are possible through the National Health Network, which links all health care providers in an electronic network. New ways of using this network might reduce the waiting time and cost of outpatient day case surgery.

Materials and Methods

In a randomised controlled trial, selected patients (inguinal hernia, gallstone disease and pilonidal sinus) referred to the university hospital are either randomised to direct electronic referral and booking for outpatient surgery (one stop), or to the traditional patient pathway where all patients are seen at the outpatient clinic several weeks ahead of surgery. Consultants in gastrointestinal surgery designed standardised referral forms and guidelines. New software has been designed making it possible to implement referral forms, guidelines and patient information in the GP's electronic health record. For "one-stop" referral, GPs must provide mandatory information about the specific condition. Referrals were linked to a booking system, enabling the GPs to book the hospital, day and time for outpatient surgery. The primary endpoints are waiting time and costs. The sample size calculation was based on waiting time. A reduction in waiting time of 60 days (effect size), 25%, is significant, resulting in a sample size of 120 patients in total.

Discussion

Poor communication between primary and secondary care often results in inefficiencies and unsatisfactory outcomes. We hypothesised that standardised referrals would improve the quality of information, making it feasible to use a one-stop approach for all patients undergoing surgery on an outpatient basis for inguinal hernia, pilonidal sinus and gallstones. In this study we wanted to investigate the waiting time and cost-effectiveness of direct electronic referral and booking of outpatient surgery compared to the traditional patient pathway, where the patient is seen at the outpatient clinic prior to surgery.

Trial registration

This trial has been registered at ClinicalTrials.gov. The trial registration number is: NCT00692497     

Fast-track barium enema: meeting the two-week wait rule for patients with suspected colorectal cancer

OBJECTIVES: To meet the introduction of the two-week wait (TWW) rule for patients with suspected colorectal cancer, a fast-track barium enema (FTBE) service was set up. This study was conducted to evaluate the success of this approach in preparation for meeting the forthcoming targets on waiting times to treatment from referral and diagnosis. METHODS: All patients were offered a double-contrast barium enema within two-weeks, except those with a palpable rectal mass. FTBE were double-reported by specialist gastrointestinal radiologists. Patients with a suspected malignancy were booked for an urgent staging CT and outpatient appointment, whilst the remaining patients were referred back to their general practitioner with a report. Prospective data were collected and two 16-month periods analysed. RESULTS: Three hundred and nine patients had a FTBE over the first 16-month period and 277 (89.6%) were seen within two-weeks. Mean times from initial referral to staging CT and first outpatient appointment were 30.7 and 36.0 days, respectively. Cancer was confirmed histologically in 32 (10.4%) patients. Of 267 patients without a malignancy, 46 (17.2%) were referred back to the colorectal outpatient or endoscopy service within 6-months. The number of referrals increased with time from a mean of 19.3 per month in the first period to 27.8 in the second, but the percentage with a suspected malignancy remained similar at 13.6% and 10.1%, respectively. CONCLUSION: FTBE diagnosed malignancy accurately and facilitated rapid staging. The TWW target was met in almost 90% of patients, whilst the impact on the colorectal outpatient and endoscopy service was minimized.     

Straight to test. Results of a pilot study in a hospital serving an inner city population

Objective  The main aims of the study were to determine the frequency with which two-week wait (2ww) referrals for colorectal cancer (CRC) could proceed directly to straight to test (STT), and the potential improvement in time to diagnosis.
Method  A telephone interview was attempted in all 2ww referrals not requiring an advocate and under 80 years. Data were assessed according to a test protocol, and where indicated a potential slot for the appropriate investigation was recorded (virtual test). All patients proceeded to clinic, following which differences in time from GP referral to virtual compared with actual requested test, and any discrepancies between virtual and requested tests were analysed.
Results  Between 8th January and 16th February 2007, there were 42 2ww referrals. Twenty-one patients were contacted, of whom 14 were suitable for STT: 13 virtual colonoscopies and one CT scan were booked. Following out-patient consultation, eight colonoscopies; three flexible sigmoidoscopies, one barium enema, and two CT scans were actually booked. There was a difference of 15.5 days between the median times of the virtual and actual test. During this 6-week period a total of nine patients were diagnosed with CRC, of whom three were referred via the 2ww pathway, but none were suitable for STT.
Conclusions  This 'straight to test' pilot study suggests a potential strategy for reducing the time to diagnosis and therefore first treatment of those identified with CRC, and offers a methodology for individual hospitals to assess their suitability to employ such a strategy.     

Impact of the '2 week wait' directive for suspected cancer on service provision in a symptomatic breast clinic

BACKGROUND: The '2 week wait' directive (Health Service Circular (HSC) 1998/242) guaranteeing that 'everyone with suspected breast cancer will be able to see a specialist within two weeks of their general practitioner (GP) deciding they need to be seen urgently' is a unique audited approach to access for the British National Health Service, the effects of which have been assessed in a non-academic symptomatic breast clinic. METHODS: New GP referrals (n = 607) were reviewed prospectively in two comparable 3-month intervals, beginning 1 April 1998 and 1 April 1999, to determine the probability of a breast cancer diagnosis from the referral letter and the effects of the directive on waiting times for appointments and utilization of clinics. RESULTS: The urgency of referral was not specified in 53 per cent of GP referrals. For the 'urgent' cases (25 per cent of all new referrals) the probability of a final diagnosis of breast cancer was 0.19. The breast specialists prospectively achieved a rate of 0.26 from 99 per cent of the same referral letters. 'Urgent' referrals did not wait significantly longer in 1999 (median 9 versus 10 days) but waiting times for new appointments overall increased (13 versus 16 days; P < 0.01), and this was greatest for 'routine' [14] versus 21 days; P < 0.001). These changes were caused by an increase in the number of clinic appointments, due to significant increases in median number of visits to diagnosis or discharge and clinic non-attendance in 1999, resulting in overbooking. Telephonic communications were associated with faster median access times (fax 8 days; telephone 2 days), relative to mailed [19] days) (P < 0.01). CONCLUSION: Breast specialists were better overall at assessing the probability of a breast cancer diagnosis. The waiting time for 'urgent' appointments was unchanged following HSC 1998/242, but there was an increased wait for other patients, especially those assessed as having a lower probability of cancer.     

A study on the routes of referral for patients with colorectal cancer and its affect on the time to surgery and pathological stage

OBJECTIVE: Firstly, to determine the proportion of colorectal cancer (CRC) patients seen within an established two week rule (TWR) system and to observe other routes of referral for CRC patients. Secondly to determine if referral route affects the interval to, and cancer stage at, definitive treatment. PATIENTS AND METHODS: GP referrals of patients with CRC were divided into direct surgical outpatient referrals (group 1) and indirect referrals to accident and emergency and medical outpatients (group 2). Data were recorded on the time to definitive treatment and the location and stage of tumour. RESULTS: There were 78 patients in group 1. Thirty (20%) patients were referred by their GP under the TWR, 31 (21%) as urgent and 17 (12%) as nonurgent referrals, to surgical outpatients. There were 69 patients in group 2. Forty-two (29%) were referred initially to the accident and emergency department and 27 (18%) to general medical outpatients. Group 1 patients were treated within a median of 70.5 days and group 2 patients within 14 days of referral (P < 0.0005). Group 2 contained tumours of a significantly more advanced pathological stage (P = 0.015) and more proximal colonic cancers (P < 0.005). CONCLUSION: Fifty-three percent of patients with CRC were referred directly to surgical outpatients, 20% under the TWR guidelines. Despite having this system in place direct referrals were slower to treatment but the tumours were still of a less advanced pathological stage. Compliance with the TWR should not be used as a means of assessing a colorectal unit's treatment of CRC.     

Implications of sub-specialisation on the waiting times of general surgical clinics.

INTRODUCTION: Controversy around sub-specialisation in a district general hospital (DGH) has been ongoing for years. AIM: To study the effect of colorectal sub-specialisation on general surgical cases. METHODS: A retrospective audit between October 2002 and September 2003, including all referrals to the outpatient clinics of a single consultant surgeon in a DGH. RESULTS: 1,055 patients were seen in outpatient clinics, of which 53% (563) were seen in rapid access colorectal clinics. Overall, 87% (914) of patients were diagnosed to have colorectal pathology. The majority of the colorectal cases were referred using the designated referral forms. There were 427 urgent, 162 soon and 325 routine referrals with colorectal pathology, and 35 urgent, 22 soon and 84 routine referrals with non-colorectal pathology. Median waiting times for urgent, soon and routine referrals were 12, 61 and 91 days, respectively, for patients with colorectal pathology, in comparison with 44, 75 and 397 days for non-colorectal pathology. CONCLUSION: This audit confirms that colorectal sub-specialisation has resulted in a significant delay in the management of patients with non-colorectal diseases. This has major implications within a DGH setting.     

Colonoscopic enema as rescue for inadequate bowel preparation before colonoscopy: a prospective,observational study

Aim Colonoscopy may need to be rescheduled because of inadequate bowel preparation. We evaluated the effectiveness of colonoscopic enema as rescue for an inadequate 1‐day bowel preparation before colonoscopy. Method Patients referred for afternoon colonoscopy were prospectively enrolled in the study during a 1‐year period. Patients took bowel preparation (polyethylene glycol) solution on the morning of the endoscopy. If during colonoscopy the bowel preparation was poor, an enema of polyethylene glycol solution (500 ml) was instilled into the colon at the level of the hepatic flexure via the biopsy channel of the colonoscope which was then removed. The patient was allowed to recover from the propofol sedation and used the bathroom to evacuate the enema. The colonoscope was then introduced and the examination continued. Results Of 504 patients undergoing colonoscopy, 26 (4.9%) received an enema. The median age was 59 (29–79) years and 19 (73%) were female. A subsequent successful colonoscopy was achieved in 25/26 (96%). There were no complications. The mean time spent for the entire colonoscopy from the initial preparation to the end of the examination including the enema was 7.6 ± 1.1 h (5.4 h preparation, 0.2 h first colonoscopy + enema, 0.66 h waiting in the lavatory, 0.33 h second colonoscopy and 1 h for recovery). Conclusion Colonoscopic enema was highly successful as rescue for patients with inadequate bowel preparation and avoided postponement of the procedure.     

Direct Access Minor Surgery service--patient satisfaction and effectiveness

INTRODUCTION: Waiting lists for surgical out-patients and elective operations are a major concern of the National Health Service. A Direct Access Minor Surgery programme in an ambulatory minor theatre area has been introduced to expedite patient treatment. The response of patients to this service has been assessed. PATIENTS AND METHODS: A postal questionnaire was offered to all patients attending for the Direct Access Minor Surgery over a period of 20 months (January 2002 to August 2003). Patients were asked about direct attendance for surgery without a prior out-patient appointment, about waiting time before operation on the day of surgery and the adequacy of pre-operative information. Overall satisfaction was assessed using a scoring system. The incidence of inappropriate referrals was analysed. The influence of the service on waiting lists and resources was assessed. RESULTS: A total of 221 patients were operated on, 257 lesions being excised. Response rate to the postal questionnaire was 55%. Of respondents, 75% thought that it was appropriate to attend the hospital directly without an out-patient clinic appointment. To 83% the waiting time was acceptable. Of patients, 90% were happy with the pre-operative information. Overall, 91% of respondents were very satisfied with the service. Inappropriate referrals were 4%. The new service reduced waiting time for minor surgery from 53 to 10 weeks. It also released approximately 140 new out-patient slots per annum. CONCLUSION: Direct Access Minor Surgery is a safe and favoured service with high patient satisfaction.     

A prospective audit of the implementation of the 2-week rule for assessment of suspected urological cancers

INTRODUCTION: All urology departments are under considerable pressure to comply with the UK Government's implementation of the 2-week rule for suspected cancer referrals. A prospective audit was planned to begin 6 months after introduction of cancer referral guidelines and a central data collection process, to investigate the local workload generated by these referrals, and compliance with the 2-week rule. METHODS: Data were collected prospectively over an 8-week period. All referral letters were examined by an independent urologist for any of the criteria defined by the regional tumour working group as suspicious of urological cancer. For suspected cancer referrals, the patient journey was followed to assess efficiency of the referral process. Results were compared with figures for '2-week rule' referrals for the Trust obtained from the UK Department of Health (DoH) website. RESULTS: In all, 234 GP referrals were reviewed, 82 fitting regional criteria for suspected cancer. Of these, (i) 13% were either marked urgent with a clear statement of 'cancer' or included a clear request to be seen within 2 weeks; (ii) 23% included no implication of cancer; (iii) 72% were seen in haematuria clinic, median time to clinic visit being 56.5 days, none complying with the 2-week rule; and (iv) of referrals not seen in haematuria clinic, median time to clinic was 21 days, with 34% compliance. With more stringent definitions of a cancer referral, DoH figures for the Trust recorded just 18 referrals over 3 months, with 89% compliance. DISCUSSION: GP referral letters meeting guidelines for suspected cancer often failed to imply or mention this. Compliance with the 2-week rule was poor, especially for the haematuria clinic. This is variably attributable to wording of GP letters, communication issues, and the sheer load of patients to be seen. CONCLUSION: DoH criteria for cancer referrals grossly underestimate the true magnitude of workload demanded of the service.     

An approach to haemorrhoids

OBJECTIVE: Many patients with haemorrhoids are investigated because of the fear of missing colorectal cancer (CRC). The aim of this study was to determine whether a primarily clinical approach regarding the need for investigation was safe and did not miss patients with CRC. PATIENTS AND METHODS: Data was collected prospectively on 589 consecutive patients with the principle diagnosis of haemorrhoids at first clinic visit. All had clinical assessment including rigid sigmoidoscopy and were treated by phenol injection or banding. They were categorized for (1) no review unless symptoms persisted -'One Stop SOS' (2) outpatient review or (3) investigation. To check for the development of CRC they were contacted by postal questionnaire or telephone interview with a minimum of one year from diagnosis and treatment. All 589 patients were cross-referenced with the Pathology database and the Hospital Information Services System. RESULTS: Four hundred and sixty-nine (80%) answered the questionnaire; 352 patients (60% of the total group) fell in the 'one stop SOS' outpatient category; 95 (16%) patients were followed up to review response to treatment for large haemorrhoids; 105 (18%) were investigated with barium enema (12%), flexible sigmoidoscopy (4%), colonoscopy (1%) and miscellaneous (1%); 37 (6%) patients were either given a haemorrhoidectomy date or referred on with a different diagnosis. No patients selected for 'one-stop' treatment developed CRC. Five (0.8%) patients were diagnosed with CRC after appropriate investigation was instituted for suspicious symptoms. One patient with distal transverse colon cancer had a delayed diagnosis as she was investigated initially by flexible sigmoidoscopy. CONCLUSION: Most patients with the primary diagnosis of symptomatic haemorrhoids do not need investigation.     

Audit of patient's waiting time to see their family doctor prior to referral to a fast-access breast clinic in the era of a guaranteed 2-week wait

PURPOSE: A prospective study aimed at assessing the effect of introduction of a fast-tract referral system for patients with suspected breast cancer and the quality of GP referrals in Barnsley. METHODS: Between February and April 2001, 70 consecutive patients with symptomatic breast disorders were seen in the fast-access breast clinic. Mean age=46 years (range 18-84). Ten non-urgent referrals seen in the study period were included in the analysis to determine the appropriateness of such referrals. Three screening criteria were used to select high-risk patients and data were recorded prospectively. Patients were classified as urgent, soon or routine based on symptomatology. RESULTS: Of the 70 patients seen, 20 were considered as urgent, 20 as soon and 30 as routine. Forty patients were seen within the '2-week wait' period. Twelve were classified on clinical grounds as malignant. Mean waiting time to see the GP was 2.2 days. Mean waiting time to see the specialist breast surgeon was 6.6 days. CONCLUSION: A fast-track system for suspected breast cancer has led to a significant reduction in the time to diagnosis and initiation of a definitive treatment, with most made within 2 weeks. Fast-track referrals is not appropriate in all cases.