Waiting times may have delayed diagnoses

External review of colonoscopy referrals

AN EXTERNAL review of referrals for colonoscopy at Southland Hospital will include at least 20 cases where surgeons believe diagnosis of cancer was delayed.

Information released under the Official Information Act (OIA) shows they will be among up to 102 referrals where concerns have been raised about the process followed. They are being reviewed by retired general surgeon Phil Bagshaw, and gastroenterologist Dr Stephen Ding, both from Christchurch.

The review is expected to be completed next month and cost about $10,000.

It was announced in October after five Southland general surgeons wrote to the Southern District Health Board chief executive Chris Fleming in September reiterating concerns raised in 2016 about what they described as ‘‘a very high incidence’’ of missed colorectal cancers in patients whose referrals for a colonoscopy had been declined.

The signatories, Southland Hospital’s general surgery clinical director Murray Pfeifer and fellow surgeons Paul Samson, Konrad Richter, Julian Speight and Jerry Glenn, were concerned about the inability of specialists to override the criteria for direct outpatient access to a colonoscopy or colonography.

The autonomy of specialist colorectal surgeons ‘‘must be acknowledged’’ and such specialists must be able to use endoscopy services unfettered by the open access guidelines, they said.

They were critical of the way the criteria were applied to them as their understanding was they were to be used by general practitioners and nongastrointestinal specialists.

‘‘It is our strongly held view that specialists in gastrointestinal medicine and surgery must have complete autonomy in deciding the necessity for endoscopy for the patients in their care.’’ They said there were numerous cases where the criteria for endoscopy had been met but requests had been declined.

‘‘In many of these cases there has been a subsequent diagnosis of gastrointestinal cancer.’’

Asked why it had taken so long to act on concerns raised by surgeons, in a written response, Mr Fleming said a number of meetings had been held in the past two years, but no consensus was reached.

During this time there had been work across the Southern region to ensure waiting times for a colonoscopy remained within and close to the Ministry of Health designated waiting times. Because of this the board was able to introduce the bowel screening programme.

He said the introduction of the programme had not had any impact on access to colonoscopies outside the programme in Southland or Otago.

Asked whether concern had been expressed that lack of access may have contributed to any patient deaths or shortened lifespans, Mr Fleming said the board was always concerned there might be a late diagnosis of cancer that could have been avoidable, and the purpose of the audit was to assess the risk of this situation. Mr Fleming said since the introduction of the direct

access criteria for colonoscopy in 2012, a minority of GPs and nonspecialist surgeons had raised concerns in Otago that referrals that would have been previously accepted were now refused.

‘‘More recently, the feedback has been that primary care referrers now have a clearer understanding of the criteria and certainty regarding referrals and subsequent timeframes that their patients should expect for investigation.’’

Mr Fleming did not see a parallel between the Southland situation and that exposed by the Otago Daily Times in 2009, when Otago GPs raised concerns about symptomatic patients being denied colonoscopies at Dunedin Hospital. Cases were cited where patients with all the accepted signs of possible cancer were refused colonoscopies and later found to have the disease.

He said the issue then was primarily based on resource constraints and long waiting times, and the board had since introduced access criteria to manage waiting times.

‘‘The situation in 2009 saw waiting times more than two years. With the new criteria in place, over 90% of patients have their procedure within six weeks of referral.’’

Terms of reference (TOR) for the review entitled ‘‘Assessment of diagnostic and treatment times for endoscopy cases’’, released under the OIA, say perceptions of delay may be causing further delays because some general practitioners are sending patients to general surgery outpatient clinics instead of considering the direct access route.

In the section headed ‘‘Problem Statement’’ the TOR state that disharmony in the surgical and gastroenterology teams has meant working together to reduce diagnostic and treatment times has been difficult.

In their letter, the surgeons said they had found communication within the endoscopy service to be either dysfunctional or nonexistent, with no real collegiality and little respect between the service leadership and general surgeons.

‘‘As a result of this we feel disenfranchised, alienated from the service, and demeaned. At times we feel bullied.’’

The review will be assessing the quality of referrals to see whether in some circumstances additional information, outside the access criteria, should be considered and the standard referral criteria overridden.

The reviewers will have access to information about the referrals and are expected to speak with key clinicians including the Southland general surgeons, district gastroenterologists, medical directors, service managers, gastroenterology and surgery clinical leaders and general practitioners. There is no mention of any contact with affected patients.

Information about other DHBs’ processes will also be gathered for comparison.

The TOR states the board will consider the recommendations of the reviewers and take all reasonable and practical steps to either implement them or make it clear where recommendations are impractical or impossible.

Since 2012 the Southern District Health Board has used national referral criteria to determine whether a patient should receive a publicly funded colonoscopy and the priority to be given to them. This is applied to all patients, regardless of who refers them.

The situation in 2009 saw waiting times more than two years. With the new criteria in place, over 90% of patients have their procedure within

six weeks of referral

Southern District Health Board chief

executive Chris Fleming