Straight to colonoscopy: the ideal patient pathway for the 2-week suspected cancer referrals?

In order to meet two-week referral targets for patients with colorectal symptoms, trusts must provide an efficient and effective patient pathway. On the face of it, the paper by Beggs et al suggests an attractive model for streamlining the process and potentially lowering costs. However, when one considers factors other than efficiency and cost effectiveness, the pathway may appear less than ideal.

In the straight-to-colonoscopy pathway described, patients are sent full bowel preparation with instructions. In response to a number of adverse incidents, the National Patient Safety Agency has published clear guidelines for the use of bowel cleansing solutions.¹ These include the need for clinical assessment to be undertaken by the clinician responsible for the procedure to ensure no contraindication or risks from their use. By the time a patient on a straight-to-colonoscopy pathway first sees the clinician responsible he or she will have already taken his or her bowel preparation. This is too late for an assessment of risk and an explanation on the safe use of the product.

A second but related concern pertains to consent. Guidelines for obtaining informed consent are widely circulated by the General Medical Council² and Department of Health.³ For elective procedures it is generally considered good practice to seek the patient's consent well in advance, with the clinician checking before the procedure starts that the person still consents. If a person is not asked to signify his or her consent until just before the procedure is due to start, at a time when he or she may be feeling particularly vulnerable, there may be real doubts as to its validity.

While it remains important to meet targets and continue to improve the efficiency of our service, we would caution colleagues in the potential for compromise in the quality of that service.