Lessons learned from Bowel Screening Pilot Clinical Director’s perspective Mike Hulme-Moir

Clinical Director Background colorectal surgery Broad role encompassing: -Public relations/Front person/Communication (Team, Patients, Management, MOH, GPs, Cancer, clinicians, Media/Public, Lab) -Quality overarching principle -Clinical work endoscopy, histopathology, -Problem solving (team based) -Expect the unexpected

Build a good team Too much for one person to do sans support Management, nursing, endoscopy, surgical, quality, GP, pathology/Lab

GPs Valuable/Vital/Essential component of our program Need total buy-in from them Education/Liaison Education takes time……lots of time, mainly after hours Need to be available preferably on the phone to talk over issues

Endoscopy Governance/Quality Currently no permanent national structure to ensure and oversee quality within a national bowel screening program NEQuip has provided excellent service to date but its future structure/funding is uncertain NOW is the time to sort out a national endoscopy governance structure with the following aims: To set acceptable standards for competence in endoscopic procedures To quality assure endoscopy units To quality assure endoscopy training To quality assure endoscopy services Governance body should service all endoscopy not just screening

Histopathology There are thousands of results in first 3 years Consistency is vital esp surveillance recommendations Less is best but one is too few!!! Nurse led histology is an answer Fellow consultants like to own their own histology Formatted letters with personalised service as needed

Cancer management Histopathology Referral processes MDM Workforce issues Initial hump and then ongoing referrals

Referral processes Robust..don’t lose pts Standardised Efficient ie get bloods and radiology done up front (2 week agreement with radiology) Colon ct, blds, info pack,mdm referral Rectal ct, mri, blds, info pack, mdm referral Provide information to patients

MDM Need one!!! Quality standard Many are easy Many are not! Rectal cancer Malignant polyps Advanced disease

Bowel Screening findings ( ) 5818 public colonoscopies in 5716 patients, 516 private colonoscopies 271 cancers in 261 patients 231 cancers/224 patients treated in public 40 cancers/37 patients treated in private 148 males, 113 females 10 public non-adenocarcinoma cancers/lesions (scc,carcinoid etc) 3 ot (r-hemi x2 and eua bx), 2 chemo/rad, 1 chemo 27 pub pts required OT for benign disease (polyps DD etc) -15 r hemicolectomy -3 ant resection +/- ileostomy -1 transverse colectomy -1 subtotal colectomy -7 TEMs or trans anal procedures 1 Private non adenoca cancers/lesions -1 chemo/rad 4 priv pts required OT for benign disease -3 r hemicolecotomy -1 high ant resection

Total BSP cancers n = 271

BSP vs Symptomatic cancer workload (2014 n= 359 of 450 P1 referrals, not including 15 non adenocarcinomas)

BSP cancer impact Surgical work load - New Pt clinic time average one hour per new cancer - (includes FSA, nurse specialist, stoma and ERAS) - Operating time on average one half day list per cancer - 11/181 pts leaked (6%) - 9 needed extra half day lists to fix and rejoin - Follow-up clinics several over 5 years - Stoma closure average of 15 per year (7.5 lists) - 2/10 FTE for BSP CD Endoscopy work load - Extra lists for complicated pts or polyps mostly under ga - Surveillance - Cancer followup scope at 3 years/5yearly thereafter

BSP cancer impact Laboratory work load (doesn’t include polyp work) - 3 hours per cancer (on average) 1 hr technician time 1.75 hrs pathologist time.25 hrs clerical time - Lab tests for inpatients Radiology - Every patient needs a staging CT - All rectal cancers need an MRI as well - Almost all major complications needed CTs, also one ivc filter for PE Ancillary services - CNS see each patient - Ethnic support services, cancer tracking - Stoma therapists (46 stomas, 2 permanent and 44 temporary) Bed space 6 day median bed stay for elective colorectal cancer surgery

Colonoscopic/Surgical complications 68 readmits from colonoscopy 6 laparotomies for bleeding(4), perforation (2) 11 leaks 9 reoperation and 2 non operative

Workload data WDHB population 575,000 Assume one surgeon 2 x 4 hour lists per week for 46 weeks per year (92 lists per year) plus 1 x 4 hour clinic, 1 x 4 hour endo list We need 0.5 FTE surgeon per year to cope with the new bsp work load but in addition there is extra work closing stomas (7.5 lists per year (2 per list). Real FTE is probably closer to.6 Acute surgery per year as a result of BSP ie 3 leaks, 2 laparotomies for bleeding/perf per year Approx.1 FTE surgery for each 100,000 population screened