Bowel cancer proposals questioned

A doctor adjusts the controls of a colonoscope. Photo: Getty Images
A doctor adjusts the controls of a colonoscope. Photo: Getty Images
The authors of last year’s damning report into the Southern District Health Board’s colonoscopy service and bowel cancer treatment waiting times are not convinced new proposals will solve longstanding inter-professional problems.

Phil Bagshaw
Phil Bagshaw
Christchurch general surgeon Phil Bagshaw and gastroenterologist Stephen Ding’s report highlighted the deteriorating relationships between Southland Hospital’s general surgeons and staff at the gastroenterology department at Dunedin Hospital.

Board chief executive Chris Fleming has released the recommendations of colorectal surgeon Andrew Connolly who was brought in last year to address what Mr Fleming called the ‘‘significant issues’’ between the two groups.

Mr Fleming said it was clear there were significant feelings held by those involved and at times this had descended into personal character attacks.

“This is unacceptable behaviour and I intend on taking more formalised action if this behaviour continues.’’

He urged everyone to put the past behind them and focus on ‘‘jointly moving forward’’.

Chris Fleming
Chris Fleming
A change in outlook would be required from within both the gastroenterology department and Southland general surgery for this to succeed.

Mr Connolly, who has since been appointed as one of the board’s two crown monitors, in a note accompanying the release of the recommendations, said it was clear to him no consensus could be reached by all the relevant clinical parties.

He emphasised that at no time did anyone raise concerns about the quality of endoscopy provided by the board. The issues related in large part to processes and the application of them.

Southland surgeons have been dissatisfied about the approval process for colonoscopies for symptomatic patients for several years, concerned that the rigid application of the national guidelines for this was causing harm to their patients. Their view was that the guidelines were designed for general practitioners’ referrals rather than those with gastro-intestinal (GI) expertise.

Mr Connolly has supported them on this, recommending that the guidelines should apply only to those patients who have not been assessed by a recognised GI specialist.

Referrals from GI specialists following clinical review of the patient should be accepted and prioritised according to the clinical risks/questions which need to be answered, his report says.

Southland Hospital. Photo: ODT files
Southland Hospital. Photo: ODT files
His recommendations also include defining GI specialist surgeons, changes to the function of the review panel for colonoscopies so its focus is on declined referrals from non GI specialists, and prospective auditing of GI specialist referrals to document the rates of detection of significant pathology, cancerous and benign, to allow clinicians to reflect on their referrals.

Commenting on the recommendations, Mr Bagshaw said he and Dr Ding felt vindicated by the report which accorded with their view that GI specialists should be able to access colonoscopies based on their clinical expertise.

In their audit report they had questioned the way since 2012 the national guidelines were used to ration all Southern direct access to colonoscopy.

Mr Bagshaw said they had found some other DHBs were also using the guidelines in the same way as Southern, so the change would have national significance.

He remains concerned the board ‘‘ploughed ahead’’ with bowel screening at the expense of providing an adequate diagnostic service for symptomatic patients, contrary to good clinical, ethical and medico-legal practice.

Mr Fleming says the board accepts all 12 of Mr Connolly’s recommendations, and he has asked for an action plan to be drawn up and endorsed by the Endoscopy Users Group by the end of March.

However, there is also scope for the Endoscopy Users Group to reach a consensus that some recommendations should be modified which would then need to be endorsed by the clinical council. If agreement could not be reached within the next two months to the action plan, Mr Fleming and the chief medical officer, Nigel Millar, would determine the ‘‘appropriate pathway’’ in conjunction with the clinical council.

Mr Bagshaw likened this process to ‘‘saying to a prisoner in the dock, could you help us appoint the judge and the jury’’.

Until now, board management which had been aware of the issues for years had been prepared to make only trivial changes, to make it look as if something was happening and if this continued, in a few months the situation would be back to where it was before, he said.

It was vital the board took heed of the final recommendation in Mr Connolly’s report, covering working with clinicians to establish mentoring and peer support as identified in the Bagshaw-Ding report.

Mr Bagshaw said this expertise had to be provided outside the board if it was to be effective.

The March Bagshaw-Ding report wanted an urgent overhaul of the management of colorectal cancer (CRC) in the Southern DHB area, drawing attention to the high incidence of CRC, the high rate of it having spread beyond the bowel at the time of initial diagnosis, the second-highest rate of emergency surgery for the disease in the country and one of the lowest colonoscopy rates.

The audit reviewed 20 cases and found that in 10 of them there had been undue delay to diagnosis or treatment.

Subsequently, board management decided it wanted an audit of 102 cases to be led by Gastroenterology Society president Dr Malcolm Arnold, although he was later replaced by Prof Ian Bissett following a perceived conflict of interest. (The society’s executive had sent a hard-hitting letter to the board, airing the society’s views of the concerns raised in the Bagshaw-Ding report. Among them was that the environment for some trainees at Dunedin Hospital was unsafe and some junior doctors reported being ‘‘broken’’ by their time at the gastroenterology department.)

The audit was to look at cases suspected of being at risk by SDHB gastroenterology and GI surgeon teams, and a control group of cases.

It is not known when this work will be completed, although Mr Fleming has said good progress is being made. No time was set in the terms of reference for its completion.

Mr Bagshaw has been critical of this audit, saying it was just playing for time.

Regardless of what such an audit found, it could not alter the fact that he and Dr Ding had already found cases where delayed diagnosis had caused harm.

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