FIT Below Threshold 2-week Wait Lower GI Pilot

BSG CSSC Service Development Prize 2023 2nd place submission by Dr Mark Follows

What were the challenges to your service and why did you need to change?

The number of 2-week wait lower GI (LGI) referrals to Norfolk and Norwich University Hospital (NNUH) colorectal team increased post-pandemic resulting in the service failing to meet 31/62-day targets. qFIT was used by the NNUH colorectal team during the COVID19 lockdown to prioritise and safety net patients with NICE NG12 lower GI cancer symptoms (1). Patients with a qFIT below 10ug/g without rectal bleeding, anal mass/ulceration, a rectal mass, or iron deficiency anaemia (IDA) received a virtual clinic appointment and a repeat qFIT at 6-weeks, and if normal discharged back to their GP. Although these patients were unlikely to have colorectal cancer (CRC), those with alarm symptoms had a 3% chance of having another cancer and required investigation. Patients without alarm symptoms with gastrointestinal symptoms needed gastroenterological input rather than being discharged back to primary care (PC). These pathways didn’t exist in Norfolk and Waveney, so patients weren’t receiving appropriate care. Please note these discussions started in Autumn 2021 before the release of the BSG FIT guidance (2).

How did you overcome the challenges?

The challenge was addressed by collaborative working between stakeholders from PC, cancer alliance, commissioners, and the trust. The proposal was for NNUH colorectal team to redirect patients with a FIT below threshold without rectal bleeding, anal ulceration/mass, rectal mass, or IDA to the Rapid Diagnostic Service (RDS) for management. The RDS is a GP-led service provided by North Norfolk Primary Care (NNPC).

A three-month pilot was proposed to run from 1 April to 30 June 2022 funded by the Cancer Alliance. To differentiate from the RDS pathway it was renamed the Lower GI support service (LGISS).

NNPC appointed a GP with extended role (GPwER) in gastroenterology in March 2022 to provide the expertise in managing patients referred on the pathway.

The pilot was delayed due to procedural issues so only started receiving referrals from 17 May. The pilot stopped on 30 June 2022 with both NNUH and NNPC wanting to continue because of the positive impact on patients and performance in the trust. Further funding had to be secured from the ICB and the pilot resumed on 15 August 2022 with funding until 31 March 2023.

During the initial pilot patients were managed by the GPwER and RDS GPs. The RDS GPs were not comfortable in managing patients requiring specialist gastroenterological input and a variation in decision making was noted between clinicians. From August 2022 onwards all patients were managed by the GPwER. This provided challenges with capacity and backfilling. NNPC provided extra paid sessions to meet demand and training was provided by the GPwER to the RDS GPs to enable them to back fill.

What were the outcomes?

136 patients were transferred from the 2-week week LGI pathway to the LGISS during the pilot in May and June 2022. An audit of 50 patients assessed the quality of referrals, patient management, and the diagnosis (attachment 1).

From 15 August 2022 until 25 January 2023 a further 301 patients had been transferred to the LGISS. An audit of 150 of these referrals concentrated on the management and diagnosis (attachment 2).

Outcomes

The quality of referrals from PC is poor with insufficient clinical information, patients not being seen face-to- face and blood and stool tests are either not done or referrals sent before results are available.

There is a lack of understanding of the 2-ww pathway and its purpose i.e., it is for exclusion of CRC not for benign conditions. Some patients were referred via the 2-week wait pathway because of a lack of alternative pathways, such as IBD clinics.

There is a lack of understanding about FIT in terms of the BCSP vs symptomatic FIT threshold and the negative predictive value of a FIT < 10ug/g in excluding CRC.

There is a lack of gastroenterology knowledge within PC. The audits show that most patients have diagnoses one would expect to be managed by GPs without the need for specialist input.

All the patients were referred under the indication 60-years old or over with a change in bowel habit (CIBH), which is a non-specific symptom, despite have a FIT < 10ug/g. We have found patients with pancreatic, lung, gynecological and prostate cancers who may have had an unnecessary colonoscopy prior to the implementation of this pathway and a delay in their diagnosis.

Positive outcomes included:

Reduced pressure on the 2-week wait LGI pathway resulting in reduced waiting times and increased colorectal cancer detection rates. Patients on the waiting list fell from over 1,000 in August to 600 by November 2022.

Improved patient care, avoiding unnecessary investigations and reduced waiting times (86.6-94.6% patients seen and discharged within 6-weeks). Patient satisfaction was high (attachment 3).

A reduction in colonoscopy numbers resulting in savings to the health economy and increasing capacity in the trust.

GP benefited from the service as the patient pathway was completed with onward referral if necessary and provision of advice and guidance (A&G) to improve learning.

What were the learning points and how can this influence other teams?

There needs to be investment in GP education to improve gastroenterology knowledge in primary care to benefit patients and reduce unnecessary referrals.

Patients can’t be triaged based on the information on the 2-week wait form and requires access to the GP record and /or telephone triage. This has implications for direct to test pathways but will protect patients from inappropriate investigations.

There needs to be better access to A&G and pathways for common conditions e.g., functional bowel disorders. This could be provided by GPwER in gastroenterology rather than increasing the burden on secondary care gastroenterology services.

Suggested pathways:

Lower GI 2-week wait
- CIBH with FIT above threshold
- PR bleeding
- Anal mass/ulceration
- Palpable rectal mass
- IDA
Rapid diagnostic clinic
- FIT below threshold with CIBH and other alarm symptoms
GPwER Gastroenterology
- FIT below threshold with CIBH with no alarm symptoms