Integrated Lower GI Pathway

Information about the implementation of the Lower GI Pathway, including FIT for symptomatic patients

This website will be the main point of information for health care professionals about the implementation of the Lower GI pathway, including the implementation of Faecal Immunochemical Test (FIT) for symptomatic patients.

This page will be updated regularly but if you need further information please email sheffieldccg.sybndcanceralliance@nhs.net.

Background

The South Yorkshire and Bassetlaw Shadow Integrated Care System is supporting the development of a system wide Lower GI Pathway. The Programme of work to develop a system wide Lower GI Pathway was initiated in January 2018, and will bring together the work undertaken by the Cancer Alliance and the Yorkshire and Humber Academic Health Science Network.

The National Picture

  • FIT testing to replace FOB for asymptomatic patients and Bowel Screening
  • Drive to increase early diagnosis of cancers
  • DG30 recommending FIT in low risk symptomatic patients
  • National recommendations around the FCP testing pathway
  • High risk patients-collection of evidence to inform future system transformation

The Local Picture

  • South Yorkshire, Bassetlaw and North Derbyshire Alliance to develop Business Case for FIT in symptomatic patients
  • Yorkshire and Humber AHSN-development and implementation of FCP pathway
  • South Yorkshire and Bassetlaw Shadow Integrated Care System-developing a system wide Lower GI Pathway which pulls both pieces of work together and maps impact

Pathology process

Pathology process - October 2018

Click here to download 

Item 5 - Integrated Lower GI Pathology Process October 2018.jpg

Updates to primary care staff

This section will be updated with the messages sent to GPs and practice staff via their own CCG. Please click on the relevant title to open the communication.

Message sent to primary care w/c 29.10.18

Message sent to primary care w/c 12.11.18

Message sent to primary care w/c 10.12.18

Message sent to primary care w/c 21.1.19

Dates for diaries - WebEx sessions, meeting dates etc.

Session/meeting

Date and time

How to book

WebEx to discuss FIT implementation

Thursday 22 November 2018

5pm – 6pm

Email rachel.humphreys5@nhs.net to register interest

WebEx to discuss FIT implementation

Wednesday 23 January 2019

2.30pm – 3.30pm

Email rachel.humphreys5@nhs.net to register interest

WebEx to discuss FIT implementation

Wednesday 30 January 2019

5.30pm – 6.30pm

Email rachel.humphreys5@nhs.net to register interest

Useful documents

Please click here for a useful document from CRUK which explains the difference between FIT for screening and FIT for symptomatic 

Faecal Calprotectin in Primary Care as a Decision Diagnostic for Inflammatory Bowel Disease and Irritable Bowel Syndrome

Click here for the slides from the WebEx session from November 2018 

Click here for a useful document from the BDA about IBS and diet - this may be useful for practice staff to give to patients when giving them a FIT kit 

Click here to view the information leafletthat was distributed the GP practises, regarding the new FIT test which will be live from 4th March 2019. . 

FAQs

Q1: What should the Practice do if the kit and sample are returned to the Practice in the envelope?
A: The Practice should post in the sample. 

Q2: What should the Practice do if kit and sample are returned to the Practice without the envelope?
A: The Practice should send this on the normal transport as stability is fine

Q3: What is the shelf life of the patient pack?
A: The shelf life of the patient packs will be 12 months from when we receive them and slightly less by the time that they are delivered to individual GP surgeries.

Q4: What is the shelf life of the patient pack once sample produced?
A: Once used the patient will send the sample back direct to the Lab and the stability of the sample in the collection device is at least 7 days at ambient temperature.  The patient leaflet advises patients to return the sample as soon as possible.
STH Lab will analyse samples with up to a maximum of 10 days between GP issue and receipt in Lab.

Q5: How can Practices follow up on patient compliance?
A: As for other tests, Practices can search for tests results and undertake necessary action e.g. follow up appointment with patient to discuss results/next steps.

If a Practice adds a Read code for when a test is requested, it will be possible to run a report of tests requested.Read codes are:

EMIS = 47K  ‘Quantitative faecal immunochemical test’
SystmOne =  Xaf0H  ‘Quantitative faecal immunochemical test’ i.e. Xaf0(zero)H

Q6: Why has a postal option been chosen?
A: ​Postal option was chosen by the patient group and will be reviewed in 12 months as part of evaluation of implementation.

Q7: How will a positive test be flagged to the GP/Practice?
A: GPs/Practices will follow their current practice protocol for accessing test results.
Refer to Q15 for further details.

Q8: How will labels for the specimens be produced?
A: These will be printed as a standard ICE label. Name/date/DoB can be handwritten. Please note: North Derbyshire, Hardwick, Rotherham and Barnsley Practices – there are no bar codes on ICE labels; the bar codes are included on the request form.
Sheffield, Doncaster, Bassetlaw Practices – bar codes are included on the ICE labels.

Q9: What is the difference between FIT test for screening versus Symptomatic patients?
A: There are different levels of analysis for screening and symptomatic processes. Please refer to the CRUK Screening vs Symptomatic Infographic for further information.

Q10: How can we avoid any confusion for patients around undertaking their FIT for screening and FIT for low risk symptoms?
A: Patients should be advised that there are different levels of analysis for screening and symptomatic processes and if even if they have had a result from a FIT screening test, a FIT provided by their GP for symptomatic patients also needs to be completed.    

Q11: Is the same FIT kit being used for FIT screening?
A: Procurement is still taking place and will be notified as soon as available.

Q12: What is the timescale for implementation of FIT for screening?
A: Provisional date for South Yorkshire and Bassetlaw – June 2019.

Q13: How will test results be returned and how will I know the difference between FIT symptomatic and FIT for screening?
A: For Sheffield Practices, test results for FIT Symptomatic will be returned via the ICE system as for all other test results. 
For all other Practices, test results for FIT Symptomatic will be returned via PMIP into SystmOne or EMIS.
FIT for Screening: results will be returned in the same way as all other screening programmes i.e. on screening specific letters.

Q14: How will I access the results on the system?
A: For Sheffield Practices, results will be available on ICE in the normal way. For non-Sheffield GP Practices: STH have set up a generic code per Practice so results will be sent to the generic inbox at each Practice. Please ensure you check this inbox. Hard copy reports are no longer available, unless requested by the Practice.

Q15: How will test results be shown?
A: When you receive the results back from the FIT test, the results will be shown as a number displayed next to the FIT reference range.

A positive result will show as: “Please refer 2WW colorectal”.
A negative result will show as: “Colorectal cancer is very unlikely in patients with low risk symptoms and no rectal mass. Suggest reassurance and safety netting to seek advice if symptoms don’t settle.”

Q16: How should a positive result be handled?
A: A positive result should then be referred on a Lower GI 2WW referral form.

Q17: What testing will be done prior to the pathology system going live and how will the results be reported?
A: We will include full system testing as part of the implementation plan. 
For result reporting, we plan to use the same protocol that we use for cytology results i.e. send to GP systems via ICE or PMIP.

Q18: If a test comes back abnormal, what will it look like?  Is there any type of alert primary care can look out for?
A: Sheffield Practices: abnormal tests on ICE usually have an asterisk and appear red. This will therefore be the same for FIT positive results.
All other GP Practices outside Sheffield: The PMIP reporting to EMIS and SystmOne will highlight a positive FIT result by:
1) being >= 10ug/g
2) having the comment “Positive test - please refer 2WW colorectal” added
3) For some GP systems there will also be a red flag next to the result as an alert; this depends on the configuration of individual GP systems. 

Q19: When will the FIT kit be sent to practices?
A: FIT kits were distributed to GP Practices between 27th February and 6th March 2019. If a Practice hasn’t received any kits, contact your local pathology lab.​

Q20: How much space is required for storage and what will the process for re-stocking be?
A: The kit packs are flat therefore storage should not be an issue. 
GPs will be stocked via their local hospital using the same system that they use for blood tubes etc.  Initial stock levels will be based on the number of patients >50 yrs at each Practice and stock will be for 2 months to minimise waste due to expiry. A restocking trigger level has been agreed and communicated to Practices via CCGs.

Q21: When will the testing/dummy run of positive results take place?
A: IT colleagues undertook end to end system testing during February 2019. This involved both an EMIS and a SystmOne Practice from each area.

Q22: What is the print time for the patient leaflet?
A: It is about 4 weeks (for the initial batch).

Q23: Who will put the label on the FIT kit?
A: Preference is for practices to put the label on the kit.  

Q24: What if the sample is returned without a sample date on the kit?
A: The label will have a ‘printed date’ on it which will be used as a guide. As a result of this together with the sample type and stability the Lab can use this as a guide.

Q25: What is the correct application of the ICE label on the kit?
A: Clear instructions will be provided via ICE, in addition to a short video demonstration. This will be available on the Cancer Alliance Integrated LGI Implementation Pathway resources webpages; it was also included in the information pack sent to all GP Practices via CCGs.

Q26: What happens if a sample request form has been issued by GP with the kit but not returned with the sample?
A: The patient instruction leaflet will request that the sample request form is retained in the kit envelope when returning. If a sample is received without this, STH Lab will check with the GP Practice.

Q27: What instructions will appear on ICE?
A: The ICE prompts are on the correct application of the label and the criteria on performing a FIT. The prompts are as follows:

ICE prompt 1:
Before:
 “Does this FIT request comply with NICE 2015 Suspected Cancer Guidelines?

i.e. Offer FIT testing to assess for colorectal cancer in people without rectal bleeding who are:
Aged > 50y and have abdominal pain or weight loss.
Aged < 60y and have change in bowel habit or iron deficiency anaemia.
Aged > 60y and have anaemia - even in absence of iron deficiency”

After: “Does FIT request comply with NICE 2015 Suspected Cancer Guidelines? i.e. assess for colorectal cancer without rectal bleeding if: > 50 with abdominal pain/weight loss; <60 and change in bowel habit or iron def anaemia; >60 and anaemia - even if not iron def”

ICE prompt 2:
Before:
 “Remember to print the ICE label at the same time as ordering FIT and ensure that the sample label is placed vertically and straight on one of the sample container flat sides.  Make sure the ICE request form or label for the sample bag is put in the patient pack”
After: “Print the ICE label at the same time as ordering FIT and ensure that the sample label is placed vertically and straight on one of the sample container flat sides. Make sure the ICE request form or label for the sample bag is put in the patient pack”

Q28: Who should I contact with any queries?
A: The Cancer Alliance Integrated LGI Pathway Implementation web pages have a number of resources.  If you are unable to find the answer to your query, these should be directed in the usual way to your CCG.

Q29: How will the process work for GP Practices in the High Peak area of North Derbyshire who normally refer to Stockport?
A: Practices will be issued with FIT test kits by Chesterfield Royal Hospital.
Test kits should be re-ordered from Chesterfield Royal Hospital.
The Lab at Sheffield will send the results back to the Practice via PMIP (pathology messaging implementation project). If the result is positive, Practices should refer as normal to Stockport.
Stepping Hill will accept patients, whether or not FIT testing has been performed – the referral process hasn’t changed. If referring due to a positive FIT, please include the FIT result with your referral. If patients have a negative FIT test and suspected cancer referral is still felt necessary, please ensure the reason for concern is clearly documented.

Q30: How sensitive is the test?
A: The false positive rate is approx. 12-14% so not all positive FIT tests are cancer. The FIT test provides a good indication.

Q31: Completion of Lower GI 2WW referral form
A: It is essential to ensure that all boxes are ticked and as much information as possible is given to ensure the straight to test process can be completed correctly.

Q32: Please can you advise how we order the FIT kits please?
A: Practices will be stocked via their local hospital using the same system that they use for blood tubes etc.  Initial stock levels will be based on the number of patients >50 yrs at each Practice and stock will be for 2 months to minimise waste due to expiry. A restocking trigger level has been agreed and communicated to Practices via CCGs.
Please contact your local hospital lab to order additional kits.

Q33: What should I look for when the kits are delivered?
A: Please note that currently the kits are delivered in an unmarked, taped-up brown box so please check all deliveries if you are unsure if you have received them.

Q34: How do patients find out about them? Are they sent info by someone... you? us? who?
Do they have to come and see the doctor for us to request it on ICE? They can't just ask for a kit?
A: Patients can't request a FIT kit themselves. The process is that if a patient presents to the GP with low risk symptoms the GP will provide the FIT testing kit directly to them. A supply has been sent to all practices for this purpose. Instructions on how to use the kit are included in the pack provided to the patient, to supplement the advice provided by their GP. The GP is required to print a label from ICE and put it on the sample tube on the kit they are providing to the patient.