If the Otago District Health Board is going to provide a colonoscopy service, it needs to do it properly, a general practitioner with about 20 years' experience says.
The doctor, who did not wish to be named because of fears for the way his referrals might be dealt with in future, said general practitioners were bearing the burden of a system which did not allow all patients with symptoms of bowel cancer a timely diagnosis.
He said he was frustrated at colonoscopy refusals for such patients .
"It's almost like I can't believe it sometimes. It does make me angry.
"It's the patients that matter. If there is a problem, we need to let the board know this is not working."
Doctors faced with refusals then had to find other ways for their patients to be treated.
If patients could afford it, they could be referred to private colonoscopy, at a cost of about $1000, or CT colonography for about $600 (but if that suggested cancer, a colonoscopy would still be required).
Public options might include referral for a barium enema or a sigmoidoscopy (by which only part of the bowel is examined). Both of these had limited value and patients might still require a colonoscopy after them.
Sometimes, doctors also referred directly to surgeons, who could then seek a colonoscopy.
The GP had examined his own practices and was satisfied they were correct.
He said the letter sent to the board this week outlining GPs' worries showed the cases of concern were not isolated.
He said he had noticed the problem with Dunedin Hospital in the past five years.
It concerned him that the clinical referral decisions made by GPs, who did not make them hastily, were not being valued.
"I think when GPs have a strong concern, it needs to be picked up and taken seriously.
"You go to work to do your very best. It's hard enough to make your own clinical calls without taking responsibility for other people's clinical decisions."
He acknowledged that a patient receiving a colonoscopy more quickly might not change the outcome for that patient, but it "gives a better opportunity for a better outcome".
"When someone comes with symptoms, you want a timely diagnosis."
Nobody wanted their patient's first presentation at the hospital to be with a bowel obstruction.
He was also concerned that patients who should receive surveillance colonoscopies because of a family history or previous bowel cancer were either being denied them or having them delayed by five years.
In Otago, thought perhaps had to be given to providing some of the public service in other ways. There could be GPs who were interested in training for such work, he said.
Overseas, nurses had also been trained for this.
The GP was one of several spoken to by the Otago Daily Times who said they did not understand what criteria were being used to decide who should receive colonoscopies.
The ODT discovered all GPs were sent an update by the board's GP liaison officer Dr Anne Worsnop outlining the situation yesterday afternoon.
Head of the general practice department at the University of Otago Associate Prof Jim Reid, said the access issue was not only a problem in Otago, and it was a symptom of the shortage of physical or financial resources which applied to other services as well.
GPs were concerned about the issue and something needed to be done by the board "and quickly".
It was also a question of priorities, and access could be made a priority.
If colonoscopies were not available, there needed to be greater access to barium enemas and consideration given to making CT colonography available publicly.
Another GP told the ODT he had stopped referring patients for colonoscopies when they had bowel cancer symptoms because he knew they would be turned down.
He opted instead for barium enema detection, which, although not as good as a test, did mean that patients were seen.
He had not dealt with patients who had been refused then gone on to develop cancer.
"I would have been pounding on the door, moaning and groaning if that had happened."
He said there had been much concern about the issue of access and it was good that it was being aired at last.
Dunedin Hospital timeline
September 2007: Routine free colonoscopy screening for people with a close family member who had bowel cancer stopped because the hospital could not cope with demand from people with cancer symptoms. At that time, some patients with symptoms had been waiting up to six months for a diagnostic colonoscopy - the change meant those in the semi-urgent category should be seen within two months.
July 2008: Otago District Health Board chief medical officer Richard Bunton questions the wisdom of plans for a national screening programme when hospitals are already struggling to keep up with colonoscopy demand.
August 2008: Board consultant advises all urgent colonoscopies could be carried out within one or two weeks and routine ones between four and eight weeks.
September 2009: Hospital advisory committee report refers to the gastroenterology department adding a regular colonoscopy list to be performed by a general surgeon, to improve service.
October 2009: GP concerns about colonoscopy access, gathered in July, are sent to the board. chief executive Brian Rousseau.
October 16: Health Minister Tony Ryall calls for an urgent report on the situation.
What to know:
• COLONOSCOPY
A procedure which examines the large bowel by inserting a fibreoptic tube containing a tiny camera while the patient is sedated. It checks for polyps or cancers. Polyps can be removed and apparent cancers can be biopsied. It is regarded as being about 95% successful in detecting cancer, but can also prevent cancer development by the removal of polyps which may become cancerous.
Bowel cancer symptoms may include:
>Rectal bleeding which is not due to piles.
>Changes in bowel habit which last for more than six weeks.
>Low iron levels in the blood, particularly a sudden drop in them.
>Weight loss.
>Abdominal pain.
Note: Such symptoms could also indicate other conditions, but the possibility of bowel cancer needs to be eliminated.
• DIAGNOSES
Stage 1: The cancer is still confined to the wall of the bowel. Treatment is surgery to remove the cancer. 90% of patients survive diagnosed and treated at this stage survive for five years or more.
Stage 2: Cancer diagnosed at this stage has spread beyond the wall of the bowel but it has not gone to the lymph nodes. Treatment is surgery to remove the cancer. Chemotherapy may be recommended and radiation therapy if the tumour is close to the edge of the resection. 70%-80% of patients survive for five years or more.
Stage 3: Cancer has spread to nearby lymph nodes, but has not spread to other parts of the body. Treatment is usually surgery to remove the cancer, sometimes combined with either chemotherapy or radiation therapy. 40%-75% of patients survive for five years or more.
Stage 4: This means that cancer has spread to other parts of the body. Treatment options include surgery, radiation therapy and chemotherapy. 25% of patients survive for five years or more.
• NATIONAL PICTURE
> The second most common cancer in both men and women.
> Each year, about 2700 people in New Zealand develop it.
> About 1200 people die each year.
> Patients with symptoms should receive a diagnostic colonoscopy within eight weeks according to national guidelines, sooner if they have "alarm" symptoms of weight loss, anaemia or abdominal mass.
> Concerns have been ongoing about the public health sector's ability nationally to provide colonoscopies for patients within three months of reporting symptoms.
> A survey in 2005 found only three of seven large centres and 11 of 17 smaller centres were able to meet the three-month referral time.
> 828 patients with symptoms had been waiting longer than six months.
> It has been estimated colonoscopy capacity nationally would have to increase by 22% to cope with the proposed screening programme, which is in the planning stages.
