METHODS

South Durham Health Care Trust serves a population of almost 225 000 in the north east of England. All patients referred to the trust between 1 August 2000 and 31 July 2001 were included in the study. Referrals were made by GPs on designated forms. The latter was custom-made and included titled boxes in order to accommodate the relevant information as outlined in box 1. The central appointments team of the trust dealt with all the referrals and surgeons had no involvement in that matter. Appointments were allocated to either Darlington Memorial Hospital or Bishop Auckland General Hospital, depending on where patients lived.

The following data were obtained from case notes, supplemented by computer based data on radiology and pathology:

1. Date of referral.

2. Referring practice and the GP.

3. Time of appointment. The two week period was calculated from the day the appointment letter was written (rather than when it was received) and inclusive of weekends and bank holidays.

4. Reasons for referral. It was assessed whether the referrals were complete and whether the guidelines were adhered to.

5. Diagnosis (including site and stage, if the diagnosis was cancer).

A literature search was performed by using Medline and relevant web sites were also consulted. Statistical analysis was performed by using SPSS 10.1 statistical package.

RESULTS

A total of 239 patients were referred to the rapid access colorectal clinic during the one year period. Ninety two GPs and 26 practices were involved in the process. All patients but nine (96.2%) received appointments within two weeks.

Two patients were excluded from the study. The first patient had undergone barium enema before the referral, which showed colonic carcinoma. The second patient died of unrelated causes shortly after the referral. One patient had carcinoma of the prostate; three patients were found to have distant (hepatic/pulmonary) metastases or disseminated abdominal malignancy with an unknown primary. They were not classified as colorectal cancers and were grouped as “other” cancers. A total of 231 referrals (97.5%) were incomplete. The rest of the findings (n=237) are summarised in table 1.

The results (table 1) showed that colorectal cancer diagnosis was of higher frequency in the subgroup of referrals that had complied with the guidelines (n=18; 85.7% of a total of 21), compared with those that did not (n=3; 14.3% of a total of 21). The association between cancer diagnosis and compliance with guidelines was statistically significant (χ²=5.5; p=0.019).

Figure 1 shows the correlation between different criteria for referral and the cancer detection rate. Out of the 18 cancer patients who met the guidelines, 12 were referred with one criterion each. The remaining six patients qualified for two criteria each due to wider symptoms. “Change of bowel habit with rectal bleed” was most commonly (28%) associated with the occurrence of colorectal cancer. Rectal bleed (32%) was the most frequent cause for referral among all the patients. Abdominal pain was the commonest (27%) associated symptom, closely followed by weight loss (16%). Colonic diverticular disease was the commonest diagnosis (29%).

Sixty GPs made a total of 90 referrals that failed to comply with the guidelines. Forty seven GPs made one such referral each (n=47). The rest of the referrals (n=43) were forwarded by 17 GPs, several of whom made up to five such referrals.

DISCUSSION

The rate of cancer detection was 8.9% over a period of 12 months. The “early” cancer (Dukes’s stage A and B) detection rate was 4.6%. Other authors had similar experiences of low “early” cancer detection rates.^5,6

A total of 96.2% of patients received appointments within two weeks. By comparison, average figures in England were 81.2 and 81.8 % during the first and second halves of 2001 respectively.⁷ It reflects the endeavour the trust has made to implement the two week appointment rule.

Table 2 shows comparative figures from similar studies. Spencer et al concluded that the two week wait could be made to run efficiently with high levels of appropriate GP referrals.⁶ Hemingway had commented that urgent review of guidelines was necessary as the latter lacked sufficient sensitivity.⁹

The number of referrals was less than the estimated figure of 2137 per annum (based on a projected number of 1900 referrals per annum per district general hospital serving a population of 200 000).⁴ It is possible that it is “early days” and it will take some time to adopt and implement the referral process fully.⁵ Interestingly, this audit did not show any rise in the number of referrals with time.

The audit showed that there was a statistically significant association between cancer diagnosis and compliance with the guidelines. This would suggest that adherence to the guidelines might possibly lead to an improved cancer detection rate.

Another area of interest was the lack of completeness (97.5%) of referrals. Family history of cancer and information given to the patient were the two key items that were missed most frequently (87.3%). It is worth mentioning that family history is thought to have an influence in 20% of cases.¹ It is also helpful to know whether the patient has been made aware of the possibility of cancer. This creates a basis for initiating further discussions, helps focus on specific issues, and improves the quality of communication. A complete referral letter also helps avoid unnecessary duplication of tests.

A total of 96 colorectal cancers were diagnosed (irrespective of the mode of referral) during the same period. Therefore it is apparent that only a small proportion of cancers (n=21; 21.8% of 96) were diagnosed through the rapid access clinic. However it is important to put the figures in perspective. Approximately 30% of patients with colorectal cancer are admitted as emergency with obstruction, pain, or perforation.³ Hence diagnosis through a rapid access clinic would, at the best, be around 70% of the total (that is, 67.2 cases out of 96). Taking this factor into account, the cancer detection rate would be 31.2% (n=21; 31.2% of 67.2).

Changes

The audit shows that a high number of referrals are incomplete and non-compliant to the guidelines. The trust has provided two week appointments in most cases, but the cancer diagnosis remains low. This does not reflect an efficient system of referral. Some changes are therefore necessary in order to make the system beneficial to the patients.

We summarise the changes as suggested in the literature:

1. The key to local implementation is full discussion of shared guidelines followed by continued education in close liaison with primary care providers.¹⁰ A number of trusts are already involving GPs in collaborative study sessions.³ This audit showed that a small number of GPs were responsible for making frequent non-compliant referrals. It would be worth considering whether a focused approach, by targeting training of these GPs, would be more productive.

2. The two week rule had been seen by the sceptics,¹¹ perhaps with reason, as “window dressing” but this also provides an opportunity for further research¹² and assessment. Therefore a change in attitude is necessary in order to adhere to the guidelines.

3. It may not be easy to remember the essential features of all the guidelines in a busy practice (there are 11 other such cancer groups!).⁴ It would be worth considering whether a change in the format¹³ of referral letters would help to improve the situation.

A mandatory tick box approach (containing all the criteria for referral) that has a direct electronic link with secondary care may be a practical solution. This format is available on NHSWeb but seems to be optional at present.⁴ This would mean that no patient whose condition would fail to meet the guidelines would slip through.

There had been a steady increase in the workload of GPs.¹⁴ An alternative system of referral should therefore be given due consideration. Selvachandran et al has suggested that a new approach is to ask patients to complete their own histories and on history alone, the risk of colorectal cancer can be predicted by using a computerised database questionnaire.^15,16 A weighted numerical score based on symptom complexes is calculated, which is comparable to a senior surgeon’s assessment of the patient consultation questionnaire. This has a high sensitivity and specificity, with a high predictive value. It is said not to add to a GP’s workload and makes the achievement of the two week rule possible.

Implementation strategies may be effective methods of achieving compliance.¹³ Audit with feedback is one such recognised strategy and may improve compliance. However, the NHS Centre for Reviews and Dissemination concluded that most strategies could be effective under some circumstances, but none would be effective under all circumstances.¹⁷

CONCLUSIONS

The introduction of guidelines entailed good intentions but raised controversies. The current system of referral to the rapid access colorectal clinic is unsatisfactory and it remains speculative whether it will provide any overall benefit to the patients. However, the criteria must be firmly adhered to in order to make correct use of the two week rule.⁵ A concerted effort, including further audits over a considerable period of time, would be necessary to assess the situation. The Department of Health is presently reviewing progress and believes that some improvements have begun.¹⁸