Report On Bowel Cancer Diagnosis Delays Finds Southland ‘inter-service warfare’

Jul 28, 2019

Bowel cancer patients in Southland have suffered unacceptable waits of months – and even years in some cases – to get diagnosed because of major failures at Southern District Health Board.

A damning independent report released today describes a state of “inter-service warfare” between bowel specialists in Dunedin and Southland hospitals, which meant patients in Southland got a poorer services than those in Dunedin.

By the time some patients got colonoscopies to diagnose their cancers, they were already dying and could only be offered palliative care.

The report’s co-author, Christchurch surgeon Phil Bagshaw, says Southern DHB has one of the highest incidences of colorectal cancer in the New Zealand, one of the highest rates of cancer that has spread beyond the bowel, one of the highest rates of emergency surgery for bowel cancer, but one of the lowest colonoscopy rates.

“Those facts in themselves show they have lost the battle against bowel cancer.

“Senior people in the DHB have known about those issues for a long time and they have not addressed those issues.”

The DHB did not appear to be delivering on its promises to implement the reports recommendations to put more resources into colonoscopy services and deal with toxic working relationships, he said.

He was horrified to see how many bowel cancer patients at Southern DHB had been admitted for emergency surgery for fistulas, which he had rarely seen in his clinical practice for the last 40 years.

The report, commissioned by the Southern District Health Board, looked at 20 cases and found delays in diagnosing 10.

One patient waited over three years for a colonoscopy that showed he had cancer – partly due to the fact he got bumped off because he had already waited so long it was thought “sinister pathology was unlikely”.

Another patient whose diagnosis was delayed a year (due to the referral letter from his GP getting lost) and four others who were delayed by up to 10 months, had to be referred to palliative care.

Others were only diagnosed once their cancers had spread.

The report describes a state of “inter-service warfare” between bowel specialists in Dunedin and Southland hospitals.

Tougher guidelines for colonoscopy referrals, which were brought in to deal with “out of control” waiting lists, were now being used “as a rationing tool”, the report said.

In some cases, Southland patients were refused colonoscopies or suffered major delays, even when they met the criteria.

“Certain access criteria appear to have been applied too rigourously and to have denied access to colonoscopy or CT colonography for cases that might well have been accepted on the grounds of specialist clinical judgement.”

A survey of other DHBs – carried out as part of the review – suggested some were also using the national guidelines to manage “a scarce resource”, which was not their intention.

“The chance in policy raises national clinical, ethical and medico-legal issues, as the national guidelines were never formally validated in their effects on health outcomes or in their intrinsic utilities.”

Patients refused a colonoscopy on the basis they did not meet the local guidelines should be able to seek a specialist appointment if their doctors considered it to be “clinically indicated”, and specialists should have the discretion to order the tests they need to do their job, the report said.

“This approach restores one option for patients who cannot afford private healthcare, and would otherwise go without investigation; it also allows GI specialist physicians and surgeons to exercise the clinical judgement and endoscopic expertise, for which they were trained and employed.”

The auditors also noted most of the doctors interviewed “showed signs of distress and some were on the verge of tears” and they concluded they could not be “working to their full potential”.

“There is a state of ‘inter-service warfare’….

“Furthermore the lack of trust and poor relationships cause delays to treatment.”

Surgeons feared the service could lose its training board accreditation for registrars in colonoscopy due to lack of training opportunities.

The endoscopy service was under massive pressure due to a number of factors, including shortages of staff and equipment.

Access to colonoscopy services had declined since the National Bowel Screening Programme started, the report noted.

LB] Of the 20 cases covered by this audit:
Eleven cases met the local guidelines for colonoscopy.
Six cases met the guidelines but were refused colonoscopy.
Four cases did not meet the guidelines.
Ten cases had an unacceptable delay in reaching a diagnosis.
After referral for colonoscopy, six cases were sent for an initial first specialist appointments, which resulted in diagnostic delays for some of them.
One case was assigned a lower waiting list priority than they should have got.[LI ]In one case documentation was insufficient to conclude the appropriate level of priority.

Southern DHB has one of the highest incidences of colorectal cancer in the New Zealand, one of the highest rates of cancer that has spread beyond the bowel at the time of initial treatment, one of the highest rates of emergency surgery for bowel cancer, and one of the lowest colonoscopy rates.

The chief medical officer Nigel Millar said since the report was completed in May, the Southern DHB had been working to ensure patients in Southland received the same treatment as those in Dunedin.
Further review on others cases

A further review will look at a further 102 cases, where there are questions over how they were handled.

Dr Millar said it was important to remember these cases were just a minority among many thousands of colonoscopies performed over a number of years.

“Any case of delayed care needs to be taken seriously. However, it is recognised that bowel symptoms, such as pain and bloating, are non-specific and in many people are not the result of gastrointestinal tumours.”

It was “impractical” to investigate everyone with these symptoms, which was why it was necessary to consider other factors, including how long the problem had been going on, unexplained bleeding and the age of the patient.

Widening access would cause waiting lists to blow out and have the unintended consequences of delaying access for patients who were more likely to have cancer, Dr Millar said.

“Unfortunately, there is always a possibility this misses some cases in people who are referred, but not accepted, for publicly funded colonoscopy.

“This is a challenging balance to strike, and we appreciate the sincere concern all clinicians experience, and have shared with us, in managing this.”

Southern DHB had joined the national bowel screening programme, and Dr Millar noted the participation rates in the South were among the highest in the country, particularly for Māori.

The programme had so far detected 80 cancers that would not otherwise have been detected, and polyps (precancerous lesions) in over 700 patients.

“This a critical step to reducing late-presentation cancers and gives us an important foundation to move forward from.”

Source: republished by arrangement.

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