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Colorectal Secondary Care guidance (Guideline)


This document is designed to provide guidance for secondary care clinicians, including those responsible for vetting lower GI referrals.  The recommended pathways have taken into account local resources and are designed so that investigation of patients with colorectal symptoms can be targeted to those with the highest risk of significant colorectal pathology.  

Referral and management triage applying FIT in symptomatic patients, shortens time to diagnosis, is cost effective and there is emerging evidence that its application may result in a migration to an earlier cancer stage at diagnosis. FIT will also prevent harm through the avoidance of investigations in patients who are not likely to have significant pathology.  

As an adjunct to clinical acumen, Secondary Care clinicians are strongly encouraged to review the referral symptoms with the FIT result. The flow chart below defines the referral triage and subsequent investigation pathways for patients referred to NHS Highland with lower GI symptoms.

NHS Highland E-vetting hub

The clinicians responsible for vetting primary care referrals in NHSH, will predominantly perform enhanced electronic vetting (e-vetting) via SCI gateway at the frequency shown below. Paper referrals will be vetted according to the same principles but are likely to incur the additional delays associated with a paper-based system.

Vetting clinicians will take decisions on investigations and appropriate patient pathways (USC, urgent or routine) in line with the guidance provided by this document.  However, these recommendations are designed as an adjunct to clinical acumen and alternative decisions may be taken for selected patients.

CategoryE-vetting frequency

Time to review target
(for outpatient appointment or straight-to-test

USCDaily14 days
UrgentDaily< 8 weeks
RoutineEvery 3 days< 3 months

Recommended lower GI investigation pathways

*Click link to see bigger version of flowchart Recommended lower GI investigation pathways

Direct-to-test (DTT)

Direct-to-test (DTT) refers to a test or investigation arranged by the secondary care provider, usually the vetting clinician, without first speaking to the patient at an outpatient appointment. In relation to lower GI referrals, the most commonly arranged DTT investigations are colonoscopy, colon capsule endoscopy or CT scan.  The judicious use of DTT plays a key role in reducing the burden on outpatient services and facilitating timely investigations. It is particularly important in patients referred on time-critical USC pathways. However, the decision for DTT is reliant on accurate and comprehensive information being provided by the referrer and is not suitable for all patients.

Key components of direct-to-test
  • A SCI gateway referral letter with a comprehensive assessment of symptoms, FIT test result and relevant blood tests e.g. Hb and ferritin
  • A primary care assessment of co-morbidity, frailty and/or functional capacity of the patient
  • An e-vetting system with the ability to link to electronic patient records e.g Trakcare/PMS
  • A reliable method of communicating the DTT decision to the patients and referrer, usually in the form of a standardised letter.
Who is suitable for direct-to-test? 
  • USC/Urgent referrals with documented colorectal symptoms and a FIT test result available
  • Patients ≤ 75 years old
  • Patients with a Clinical Frailty Scale of < 3
  • Previous relevant investigations should also be considered when making a decision for DTT.
Who is not suitable for direct-to-test?
  • USC/Urgent referrals with a FIT test either not done or not available
  • Patients >75 years old
  • Patients with a Clinical Frailty Scale of > 3
  • Elderly, frail or co-morbid patients or those with vague or non-specific symptoms are usually better assessed in an outpatient clinic.

Colorectal MDT

The colorectal multidisciplinary team meeting (MDT) takes place every Friday at 2pm via MS Teams. The meeting makes recommendations regarding the management of patients with lower GI malignant disease. This is predominantly patients with colon or rectal adenocarcinoma but patients with anal squamous cell cancer, small bowel malignancy or appendiceal tumours may also be discussed. The meeting provides sub-specialty support and advice to patients from across NHS Highland (Raigmore, Belford and Caithness) and NHS Western Isles. The meeting includes representation from the following services:

  • Colorectal Surgery
  • GI Oncology
  • Pathology
  • Radiology
  • Clinical Nurse Specialists
Meeting Chair

The meeting is chaired on a rotational basis between five named colorectal consultant surgeons:

  • Colin Richards
  • Raymond Oliphant:
  • Thanesan Ramalingam:
  • Michael Walker:
  • Angharad Jones:
Adding patients to the MDT

Patients are added to the MDT via a dedicated online form, available via Formstream. Only certain clinicians have access to this form and the ability to add patients for discussion. If a patient is unknown to the department and requires an MDT discussion, the details should be sent via secure NHS email to one of the above named colorectal surgeons. It is strongly encouraged that the clinician who has current responsibility for the patients care attend the meeting to provide background information on the patients fitness or personal wishes. However, the meeting Chair will present the case and the document an outcome (see below).

For those clinicians with access to the Colorectal MDT form on Formstream, please choose a date (MDT is every Friday afternoon at 2pm) when all the relevant biopsies, imaging and endoscopy results will be available. Discussing patients with outstanding results usually causes unnecessary re-discussion and increases workload. This is particularly relevant to patients with a new diagnosis of rectal cancer where an MRI is required to complete staging prior to MDT discussion.

When completing Formstream it is important to be as thorough as possible, including all relevant patient details e.g. co-morbidity or assessment of frailty in conjunction with endoscopic, radiology and histological results. When a clinician has completed Formstream, it is important to remember to then press “Save Draft” and not “Verify”. If the form is verified, it becomes locked to future editing and a copy is automatically uploaded onto Trakcare/PMS. The only way to unlock a form in this scenario is to contact the hospital IT department. 

The deadline for adding patients for MDT discussion is 6pm on Tuesday on the week of the meeting. This is designed to give adequate time to the meeting Chair, radiologist, pathologist and oncologist to report and consider each case. Adding additional patients after this deadline has passed is discouraged and will only be possible with the express agreement of the meeting Chair. Normally, this is only given in cases where a time-critical decision is required.

A list of confirmed MDT cases, along with an invite to join the MS Teams meeting is emailed out each week to the MDT group members by Shirley Caddle (

MDT outcome

The MDT outcomes will be signed off at the end of the meeting by the Chair and a copy of the Formstream outcome document will be automatically uploaded onto Trakcare/PMS. The Chair will only communicate directly with the referrer in selected circumstances e.g. by prior agreement with referring clinician.

Last reviewed: 01/08/2022

Next review date: 31/08/2025

Version: 1

Approved By: Awaiting approval of TAM Subgroup of the ADTC

Reviewer name(s): Colin Richards, Kenneth Walker .

Document Id: TAM521

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