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.     

Two-week rule: Has prioritisation of breast referrals by general practitioners improved?

INTRODUCTION: A 9-month audit, soon after the introduction of the 2-week rule in the UK in 1999, showed that a significant number of breast cancer patients were referred as non-urgent by their GPs, when the goal is that all suspected breast cancer patients should be seen by a hospital specialist urgently within 2 weeks of referral. The aim of this study was to determine whether GP grading of referrals into urgent and non-urgent had improved. METHOD: A retrospective review of GP referrals over 8 months, between September 2003 and April 2004, with regard to their urgency, subsequent diagnosis and the use of proformas (standardised referral formats) was carried out. The results were compared to the 1999 audit. RESULTS: Eighty-two of 1178 patients referred by GP had breast cancer, versus 115 of 1176 patients referred in 1999. Sixty-eight per cent (56/82) of breast cancer patients were referred as urgent, compared to 47% (54/115) in 1999 (P=0.005). A proforma was used in 47% (548/1178) of GP referrals while no proforma was used in 1999. Sixty-five of the 82 cancer patients were referred with a proforma and 85% (55/65) were referred as urgent. CONCLUSION: GP prioritisation of referrals has improved since 1999. With the use of proformas a significant number of patients with cancer were referred urgently.     

Triaging referral to a specialist breast clinic

BACKGROUND: The aim of this study was to determine the effectiveness of a triage system in predicting patients with malignancy among those referred to a specialist breast clinic. METHODS: A retrospective study of all referrals seen at the specialist breast clinic from January 2002 to June 2002 was conducted. The triage system allocated an urgent appointment if (i) urgent referral was requested by the referring physicians or (ii) 'non-urgent referral' was made and any one of the following 'high-risk' criteria were present: aged more than 50 years when presenting with breast lump, lump larger than 3 cm, bloody nipple discharge or physical signs suggestive of malignancy. Routine appointment was given if these conditions were not met. The outcomes of individual groups were assessed. RESULTS: Three hundred and sixty-three referrals were analysed and 44 cancers (13.2%) were diagnosed. The mean waiting time for urgent and routine appointments was 19 and 154 days, respectively. There were 108 urgent referrals and 21 (19.4%) cancers were diagnosed. Ninety-two patients were given an urgent appointment because of the presence of high-risk criteria, and 21 cancers were detected (22.8%). After the two-stage triage, breast cancer was subsequently diagnosed in only 2 out of the remaining 163 patients (1.2%) given a routine appointment. CONCLUSION: Most of the patients with cancer (96%) were given an urgent appointment through the triage system. In addition to the assessment by referring physicians, certain high-risk criteria are helpful to select patients who should be seen urgently.     

Referral prioritization at the specialist breast clinic

Aim: The workload of specialist breast clinics is ever increasing and long waiting time is expected. Clinical guidelines were employed to sort out the priority of consultation. The effectiveness of this system is reviewed. Methods: All referrals seen at the specialist breast clinic from January 2002 to March 2002 were retrospectively studied. The guidelines for allocation to urgent appointment included – (1) urgent referral as determined by referring physician; (2) referral not labelled as urgent but certain ‘high risk’ criteria were present: age more than 50, lump bigger than 3 cm, bloody nipple discharge and physical signs suggestive of malignancy like irregular or fixed breast lump. Routine appointment was given if these criteria were not met. Patients with imaging and cytology results available before specialist consultation were given appointment with reference to the investigation result and excluded from the present analysis. Outcome of the patients in each category was assessed. Results: 165 referrals were analysed and 14 cancers were diagnosed. The mean waiting time for urgent and routine appointments were 2 weeks and 20 weeks, respectively. There were 52 urgent referrals and eight (15.4%) cancers were diagnosed compared to six cancers (5.3%) diagnosed in the 113 non‐urgent referrals. Forty‐two patients among these 113 patients were given urgent appointment due to the presence of high‐risk criteria and as a result, all the six patients with cancers were allocated to urgent appointments. None of the patients given routine appointment had breast cancer diagnosed. Conclusion: It was reassuring that no cancer was diagnosed in patients who had been allocated to routine appointment. In addition to the clinical assessment by the referring physicians, certain ‘high‐risk’ criteria serve as useful guides in assigning the urgency of specialist consultation.     

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.     

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.     

Audit of referral practice to a fast-access breast clinic before the guaranteed 2-week wait

Currently in the fast-access breast clinic at Eastbourne District General Hospital, the specialist determines the level of urgency of a referral. With the new '2-week wait' imposed by the Government since 1 April 1999, the determination of urgency has transferred to the general practitioner. Therefore, we decided to audit the current situation to see whether the guidelines were adequate for this change of emphasis. A total of 100 consecutive patients referred to the fast-access breast clinic were evaluated to assess the quality of referrals and the effectiveness of the clinic. Only 80% of the referrals adhered to the guidelines; 73% of the referrals were deemed by the specialist to be urgent and seen within the 2-week time period. All patients who were subsequently diagnosed as having breast cancer were seen within 2 weeks. The audit indicates that further specific changes could be made to the guidelines to improve the referral practice.     

A team approach to musculo-skeletal disorders

INTRODUCTION: The majority of patients with musculo-skeletal problems referred to hospitals in the UK have to wait for months, if not over a year, before finally seeing an orthopaedic surgeon. In Stobhill Hospital, Glasgow, the waiting time for an out-patient appointment was 182 days in 1995, with only 20% of the referrals requiring surgery. The aim of this paper was to reduce the out-patient waiting times based on a co-ordinated team approach. METHODS: An outpatient musculo-skeletal service was developed over a 7-year period at Stobhill Hospital. The traditional consultant-based model, in which the consultant and a trainee saw all new patients referred to the hospital, was gradually replaced with a team approach, based on continuous reconfiguration of the roles of the orthopaedic surgeon and rheumatologist and extending the roles of nurses, physiotherapists and podiatrists. This was achieved by: (i) protocol-based daily triage for all referrals to the most appropriate health professional in the team, by the senior out-patient nursing staff; (ii) allocation of appointments based on clinical priority, with a fast-track for urgent cases; and (iii) improvement of inter-disciplinary communication, facilitating the retraction as well as the extension of traditional roles. RESULTS: Despite the number of GP referrals to the orthopaedic out-patient department at Stobhill nearly doubling in a period of 5 years, the out-patient waiting time decreased by about 50% (90 days from 182 days). This reduction in waiting times improved patient and GP satisfaction levels. We also noticed an improved morale and personal development of the health professionals as they saw patients appropriate to their skills and expertise. CONCLUSION: The team's experience demonstrates the effectiveness of a team approach in tackling what is often seen as the insoluble problem of orthopaedic waiting times. This is based on excellent communication and collaboration, with a clear aim of improving patient care that is evidence based.     

Do patients with frank haematuria referred under the two-week rule have a higher incidence of bladder cancer?

INTRODUCTION: The new NHS guaranteed that everyone with suspected cancer would be able to see a specialist within 2 weeks of their GP deciding that they need to be seen urgently. We investigated whether referrals under the two-week rule for frank haematuria results in a clinically significant advantage over normal referral pathways in patients with suspected bladder cancer. PATIENTS AND METHODS: Patients referred for frank haematuria specifically under the two-week cancer rule were prospectively recorded over a 2-year period. Results of haematuria investigations were compared to a control group of routine frank haematuria referrals. RESULTS: Of the 32 patients in each group, four bladder cancers were found in the 2-week rule group and five bladder cancers were found in the control group (P > 0.05). The number of other demonstrable urological causes of frank haematuria was also the same in the two groups. CONCLUSIONS: The incidence of bladder cancer and other urological pathologies is the same irrespective of referral pattern. It is not clear whether seeing such patients within 2 weeks confers any clinically significant advantage over conventional referral pathways. Not all patients with macroscopic haematuria are referred or seen under the two-week rule, this has considerable clinical governance implications for all departments of urology.     

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.     

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.     

A single common urgent pathway for all colorectal referrals reduces time to diagnosis and treatment

OBJECTIVE: Guidelines for the urgent referral of patients with suspected colorectal cancer were introduced in 2000. They aimed to facilitate the prompt diagnosis and treatment of patients with symptoms suggestive of malignant disease. Recent assessment of these guidelines has suggested that although they identify 9-14% of patients with colorectal cancer, they may be used inappropriately and may lead to delays in treatment for those patients with cancers whose symptoms do not fit the guidelines. We aimed to assess the effect of introducing a single pathway for all referrals irrespective of indicated urgency. METHOD: All referral letters to a single consultant colorectal surgeon over a 6-month period were coded 'urgent' irrespective of the indicated urgency on the original referral letter. Data was collected prospectively on 47 patients diagnosed with colorectal cancer identified over the trial period. Patient demographics, the mode of presentation, urgency of referral and waiting times were documented. RESULTS: Following the introduction of the common urgent referral pathway, no patient waited longer than 62 days from referral to treatment or 31 days from the decision to treat to first treatment, thus meeting government targets introduced in 2005. CONCLUSION: The introduction of the urgent referral guidelines has accelerated the referral pathway for patients with symptoms suggestive of colorectal cancer, although this is at the expense of the majority of patients who present via conventional pathways. The introduction of a common urgent pathway allows prompt diagnosis and treatment and is of particular benefit for the majority of patients not referred via the 2-week standard. Until a more accurate method of identifying the highest risk patients is implemented, we suggest that all patients are seen on an urgent basis.     

Reducing surgical outpatient waiting is not the solution to meeting the 2005 colorectal cancer target

OBJECTIVES: The majority of colorectal cancers (CRC) are not diagnosed through the Rapid access route (RAR) and follow-ups (FU) may prolong outpatient-waiting time for new referrals. The aim of this study was to assess the relative contributions of an efficient colorectal clinic and a stringent colonoscopy booking system on the total journey time for CRC. PATIENTS AND METHODS: We reduced the number of follow-up appointments with the introduction of 'Paper clinics'. The composition of the new clinic was determined by the known cancer yield through RAR and non-RAR route. A prospective analysis of clinics and CRC journey times was undertaken from November 2003 for 13 months, with the new outpatient clinic template introduced in December 2003. This coincided with a stringent policy on referral pattern for colonoscopy. RESULTS: In our hospital, only 4% of RAR yield CRC. Seventy-five percent of our CRC are referred through the non-RAR route. Eighty-one percent of follow-ups in a 'paper clinic' were discharged. A flexible template for the outpatient clinics, introduced a corresponding reduction in follow-up and increased urgent and routine slots. There was a progressive drop in the follow-up to new ratio and the waiting times for routine and urgent category decreased from a median of 15.9 and 3.4 weeks to 6.7 and 0.7 weeks, respectively (P < 0.001). Average waiting times for all categories fell from 13.35 weeks in November 2003 to 3.5 weeks in December 2004, while the number of patients waiting less than 4 weeks rose from 46% to 71%. This was associated with reduction in total journey times from 93 days to 62 days (P < 0.05). DNA rates remained unaffected. CONCLUSION: Modifying outpatient clinic composition with 'paper clinics' reduces the waiting time for all referrals to a surgical clinic with a modest effect on CRC clinic waiting time. Reduction in the total waiting time to first treatment (for CRC) is due to reducing the demand on colonoscopy in favour of barium enema. Redirecting the flow of patients towards barium enema is perhaps one way of improving the existing CRC journey time to first treatment, within existing resources. Achieving the 62 day target for cancer journey time will be difficult unless traditional surgical clinic habits are challenged.     

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.     

The management of women with breast symptoms referred to secondary care clinics in Sheffield: implications for improving local services

Information was collected about 302 women referred for breast symptoms and seen in surgical outpatient or outreach clinics during one month at two hospitals in Sheffield. Three-quarters of the women (n = 244) were referred to specialist breast clinics, 22% (n = 70) were referred to general surgical clinics and 3% (n = 6) were referred to outreach clinics. The ages of the women ranged from 16 to 85 years with a mean and median age of 45 years. Some 200 women (66%) presented with a lump or lumpiness, 42 women (14%) presented with pain, 29 women (10%) had a skin and/or nipple problem, and the remaining 31 women (10%) were concerned about their family history or reported other symptoms. A total of 23 women (8%) were diagnosed as having cancer, 180 (60%) were diagnosed as having benign breast disease, and 99 (33%) were diagnosed as normal. Of the 23 women with cancer, 22 were over 40 years of age; 21 women presented with a lump, one presented with pain, and one presented with metastatic disease. The time required to reach a final clinical diagnosis varied from the same day as the clinic visit to 35 weeks, with a median time of 3 weeks. Surgeons assessed the appropriateness of GPs' referrals for 257 cases and judged that 122 (47%) could have been managed by a GP. The implications of the findings for the organisation of specialist outpatient clinics are discussed, and a categorisation of women as either urgent or routine cases is suggested.     

Outcomes in 2748 patients referred to a colorectal two-week rule clinic

OBJECTIVE: To assess the 3-year outcomes of a nurse-led, one-stop, 2-week rule (TWR) clinic for suspected colorectal cancer (CRC) in a large teaching hospital. METHOD: Data were collected prospectively from January 2002 to December 2004. In total, 2748 patients were seen over the 3-year period. The ratio of male:female subjects was 1190:1558 (43%:57%). Median age at presentation was 66 years (range 17-96). RESULTS: A total of 1363 (49.6%) nonconforming referrals were made; 1300 patients (47.3%) underwent flexible sigmoidoscopy during their initial assessment in clinic; 1439 patients (52.4%) underwent a barium enema during the course of their investigation; 2503 patients (91.1%) were seen within 14 working days. The median overall wait for the initial clinic appointment was 10 days. The annual number of patients seen was similar over the 3-year period. A total of 174 cancers (6.3%) were identified which accounted for 36.4% of all CRCs diagnosed during the study period. Nineteen cancers presented in the nonconforming group (1.6% of all non-conforming patients). Rectal tumours accounted for 59.8% (n = 104) of all cancers diagnosed while right-sided tumours accounted for only 10.9% (n = 19). Advanced tumours accounted for 73.0% (n = 127) of the total; 133 (76.4%) cancer patients underwent some form of surgical intervention. CONCLUSION: A specialist nurse-led, one-stop TWR clinic for suspected colorectal cancer is sustainable and can be run successfully with over 90% of referrals seen within the targeted time period. The proportion of non-conforming referrals was high and a large number of advanced and unstaged tumours was observed. Low numbers of proximal tumours were detected.     

The two-week waiting time standard for cancer: a neurosurgical perspective

The implementation of the two-week wait initiative for cancer referrals in the NHS has had a major impact on outpatient services. A low clinical detection rate among GPs for neurological cancer has resulted in a large number of urgent referrals with a low yield of positive diagnoses. We have devised a strategy for minimizing the impact on outpatient clinics: patients are scanned prior to clinical review and those with normal scans are referred back to the GP without a clinic appointment. Out of 69 referrals of suspected CNS cancer made in 2003, 61 were scanned and six resulted in a positive diagnosis. The equivalent of 10 clinics was saved, and an increased speed of diagnosis and treatment was achieved with no compromise in patient care. Our study illustrates the consequences of the 2-week wait initiative on the neurosurgical service, and proposes an effective and safe solution.     

The impact of the two-week wait rule on the diagnosis and management of bladder cancer in a single UK institution

INTRODUCTION

The objective of this study was to investigate the impact of the 2-week wait rule on patient waiting times for the diagnosis and treatment of bladder cancer.

PATIENTS AND METHODS

Data reporting the waiting times from diagnosis to treatment for 100 consecutive patients newly diagnosed with bladder cancer immediately before and after the implementation of the 2-week wait rule were compared. The data were collected both prospectively and retrospectively from cancer multidisciplinary team meeting files and patient records. Various steps of the patient pathway were analysed including waiting times from referral to consultation as well as time to investigation and first treatment. Data were also analysed based upon tumour stage/grade and whether referrals were made on an urgent or routine basis.

RESULTS

One hundred newly diagnosed patients with bladder cancer in each group covered a period of 4–5 years (1997–2001 and 2001–2006). Following the introduction of the 2-week wait rule, there was a 47.6% reduction in the time from referral to first consultation with a specialist (42 days vs 22 days; P < 0.001). The time between first investigation and treatment has not reduced significantly. We also found that, despite the introduction of the 2-week wait rule, only 42% of the patients were diagnosed with bladder cancer using this pathway. Patients referred as ‘routine’ waited longer to be seen in hospital although there was no significant delay in receiving treatment.

CONCLUSIONS

The introduction of the 2-week wait rule has significantly reduced the time patients with bladder cancer wait for their first consultation with a specialist. However, there is no significant change in the time between first consultation and treatment.     

The fourteen-day rule and colorectal cancer

OBJECTIVE: To examine the effect of the fourteen-day rule on the colorectal service of a district general hospital. METHODS: Prospective audit of all patients referred by general practitioners to the colorectal service of a district general hospital serving a population of approximately 300,000 people. The main outcome measures were: (i) mean interval in days from referral to first clinic appointment; (ii) first clinic appointment to diagnosis; and (iii) overall interval from referral to diagnosis. RESULTS: There was a change in the referral pattern with greater numbers of 'fourteen-day rule' and urgent referrals than expected (P < 0.001). The mean time interval from referral to diagnosis was reduced (P < 0.01). This was due to a reduction in the wait for a first clinic appointment (P < 0.01). The wait between first appointment and diagnosis was unchanged (P < 0.05). Waiting times for patients referred as 'routine' or whose GPs did not specify a priority also improved. CONCLUSIONS: The 'fourteen-day rule' with respect to colorectal cancer has reduced waiting times for a first appointment to see a specialist. Further improvements will require additional resources to reduce the delay for investigations. The effect on long-term survival remains to be seen.     

The National Stroke Strategy – Is it Achievable?

INTRODUCTION

Timing of intervention in symptomatic carotid disease is critical. The UK Department of Health''s National Stroke Strategy published in December 2007 recommends urgent carotid intervention within 48 h, in appropriate patients, who have suffered a transient ischaemic attack (TIA), amaurosis fugax or minor stroke. Despite the running of a rapid-access clinic for patients with symptoms of TIA, the time from symptom to surgery is rarely less than 2 weeks. To date, there has been little published research on the UK public response to the symptoms of TIA, and no study at all of the response of primary care to such patients. The aim of this study was to ascertain both these responses to see whether a 48-h target is achievable.

PATIENTS AND METHODS

A total of 402 men attending our aortic aneurysm screening sessions were asked to complete a questionnaire requesting their most likely response to an episode of amaurosis fugax or TIA. All 45 GP practices in the hospital catchment area were asked how they would respond to patients requesting to be seen with the symptoms used in the questionnaire.

RESULTS

Nearly one in six patients would ignore the symptom unless it recurred, approximately half would request a GP appointment and a third would see an optician if they had amaurosis fugax. The mean waiting time to see a GP was 2 days for a routine appointment and within 24 h for an emergency appointment.

CONCLUSIONS

It is clear that a significant number of people would ignore the first symptom of carotid ischaemia; for those with amaurosis fugax, nearly a third would initially seek help from their optician. Those given a routine GP appointment would have to wait a minimum of 2 days. If the Department of Health is serious about reducing the incidence of stroke and introducing a target of 48 h from symptom to treatment, then there needs to be a wide-spread public and healthcare education programme, in particular alerting opticians and GP receptionists that these symptoms constitute a medical emergency.