Clinical governance lead Dr Paul Twomey describes the development of local guidelines for referral of patients with suspected colorectal cancer, within the NE Lincs initiative

The principal cancer areas addressed by the North East Lincolnshire Clinical Development initiative in 1999/2000 were breast cancer and colorectal cancer. These areas were chosen because they were in the initial tranche of cancers included in the Calman-Hine guidance.

The initiative also provided us with the opportunity to review the local service in each of these cancer areas.

The background to the initiative, its objectives, and its use to facilitate the development of local breast cancer referral guidelines in line with the Calman-Hine guidance, and to review the local breast cancer service, were described in full in the November issue of Guidelines in Practice.

This article will describe the development of local colorectal cancer guidelines and review of the local cancer service in this area, within the NE Lincs initiative.

Implementation of the Calman-Hine guidance had highlighted significant capacity issues for the colorectal cancer service, as it had for the breast cancer service.

In developing the local colorectal cancer guidelines we employed the same framework for the development of guidelines (care pathways) that had been used in drawing up the breast cancer guidelines (see Figure 1, Guidelines in Practice, November 2000, Vol 3).

Local service review meeting

The meeting was held on 8 February 2000, and was well attended by more than 60 local health professionals including 36 GPs and the two local colorectal surgeons. There was good attendance from clinical, administrative and support staff including audit staff.

The following aspects were reviewed:

  • Guidelines
  • Are they helpful?
  • Are we following them?
  • Care pathway
  • Is it appropriate for patients with treated colorectal cancer to be followed up in primary care?
  • Calman-Hine
  • Urgent vs routine referrals
  • What constitutes an urgent referral?
  • Review of latest national guidance
  • Consideration of proposed updated guidelines with supporting proposed referral proforma

Conclusions from the meeting

The meeting acknowledged that the guidelines circulated to primary care in November 1998 reflected current national guidance well. However, the initial data collection (September 1998 to June 1999) (Figures 1, 2a and 3, below) , which looked at referral by GPs of patients with suspected colorectal cancer, showed limited adherence to the guidelines.

Figure 1: Locally agreed standards

The following details should be provided within the referral letter in 80% of cases:

  • Change in bowel habit (present or absent)
  • Rectal bleeding (present or absent)
  • Perianal symptoms (present or absent)
  • Abdominal distension/pain (present or absent)
  • Family history information (present or absent)
  • Bodyweight information (present or absent)
  • Information with regard to an abdominal examination including a rectal examination
  • Current medication and known allergies
  • Basic primary care investigation: full blood count (for detection of iron deficiency anaemia)


Figure 2: Methodology

(a) Baseline data collection (234 patients)

  • 10 months (Sep 1998 to Jun 1999)
  • Retrospective
  • Over 50 years old
  • Had a barium enema

(b) Audit (73 patients)

  • 3 months (Jul to Sep 1999)
  • Concurrent data collection
  • Over 50 years old
  • Had a barium enema


Figure 3: Comparison of the baseline and audit results presented at the colorectal cancer service review meeting in February 2000
baseline and audit results

The audit carried out in the subsequent 3 months (July to September 1999) (Figures 1, 2b and 3) compared utilisation of the guidelines after their adoption within the local clinical initiative. It was supported by 99% of local GPs and showed improved adherence to the guidelines.

The updated referral guidelines (see Figure 5, below) were felt to be helpful and to communicate the current guidance effectively. The meeting also felt that the referral proforma (Figure 4,below) would facilitate more comprehensive adherence to the guidelines.

Figure 4: NE Lincs referral proforma for colorectal cancer
patient referral form
Figure 5: NE Lincs referral guidelines for colorectal cancer
referral guidelines

The local philosophy of a guideline was considered appropriate and reflected the statement made by the Royal College of Radiologists in 1990 in their review of guidelines:

'A guideline is not a rigid constraint upon clinical practice but a concept of good practice against which the management of the individual patient can be considered'.

The meeting strongly supported the philosophy of the Tumour Working Party for Lower Gastrointestinal Cancer (chaired by Mr MR Thompson, colorectal surgeon, Portsmouth) that it was appropriate to adopt a 'wait and watch' policy for patients at low risk of colorectal cancer presenting with specific colorectal symptoms.1 The policy acknowledges the potential harm that may result from unnecessary investigations for some patients.1

This philosophy also supports the appropriate role of the GP as a 'gate-keeper'1 for referral of such patients.

The referral guidelines included the management of patients with a family history of colorectal cancer. This was felt to be an area for which there should be a coordinated approach across the local health community.

The meeting felt that it was appropriate for treated colorectal cancer patients to be followed up in primary care in a similar manner to those receiving treatment for breast cancer.

Action plan

  • The colorectal cancer guidelines and referral proforma supported by the service review meeting to be adopted by the local health community from 1 April 2000.
  • A project team to be identified to take forward the proposal of following up treated patients with colo-rectal cancer within primary care.
  • The guidelines, referral proforma and service to be reviewed in April 2001.

Further work has led to the development of a framework to enable the appropriate follow-up of patients with treated colorectal cancer after the first anniversary of their surgery.

Within the programme there is an agreed assessment undertaken in primary care (supported by appropriate investigations carried out by the acute trust) with an agreed reporting mechanism.

The programme supports the management of the 'whole patient', improved access to cancer services and accreditation requirements. Access is particularly important as the majority of recurrences following local review have been shown to present in the interval between planned follow-ups.

The programme has the support of the primary healthcare teams, the NE Lincs acute trust colorectal service and the Community Health Council. We hope to implement the programme with the support of the local cancer investment programme.

The achievements to date within the programme are the result of partnership working and the wide involvement of local health professionals.

Selection of the project by the PCG in conjunction with NE Lincs acute trust was in response to the opportunity presented by Calman-Hine and the local development of cancer guidelines.

Our aim is to show that clinical governance can make a clinical difference, and lead to the development of services across the local community. By this process we hope to create a momentum to support a sustainable clinical governance programme and implement our local philosophy – the creation of a positive local environment to support the development and performance of all local health professionals and hence local service development (represented diagrammatically in Figure 6).

Figure 6: Local philosophy of clinical governance
graph of indifivual development/performance
  • It is appropriate to acknowledge the key input of specific individuals including our local colorectal surgeon Mr H Pearson. Our local Quality Effectiveness and Development Department, led by Sarah Johnstone, in collaboration with The Diana, Princess of Wales, Audit Department, has provided the principal administrative support.

  1. Thompson MR for the Lower Gastrointestinal Cancer Working Group 2000. Guidance for General Practitioners and Primary Care Teams: Referral of patients with the symptoms of colorectal cancer.

Guidelines in Practice, December 2000, Volume 3
© 2000 MGP Ltd
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