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

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Abstract
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. 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. 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. 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.