Warning

Audience

  • North NHS Highland only
  • Secondary Care settings only
  • Adults only

This document is 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 NHS Highland, 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 suspected cancer), 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.

Category E-vetting frequency

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

USC Daily 14 days
Urgent Daily < 8 weeks
Routine Every 3 days < 3 months

Recommended lower GI investigation pathways

Raigmore E-Vetting Hub

Are symptoms consistent with Scottish Cancer Referral guidelines?

Is a FIT, FBC, and eGFR available?

Is there an assessment of frailty/comorbidity?

USC Pathway
Urgent Pathway
Routine Pathway

Colorectal Symptoms + FIT >20

OR

Iron deficiency anaemia + FIT >20

OR

Abdo or rectal mass

Colorectal Symptoms + FIT <20 or not available

OR

Other symptoms requiring urgent secondary care

Anorectal bleeding + FIT less than 20

OR

Proctology (e.g. fistula, fissure, pilonidal)

Pelvic floor symptoms, e.g. faecal incontinence

  • Consider DTT for Age <75 or CFS ≤3
  • Consider ad hoc PA/CNS phone review for Age 75to 80 + CFS ≤3
  • Consider Flexi-sig if bleeding predominant + FIT <100
  • Colorectal Symptoms/IDA + FIT >20 → C-scope or alternative (CCE, CTC, CT)
  • Abdo/rectal mass → USC F2F clinic
  • Age >80 or CFS >3 → USC F2F/Virtual Clinic

Urgent clinic (F2F or virtual)

Or DTT CCE, flexi sig, colonoscopy

Routine F2F Clinic

Pelvic Floor Pathway

Colorectal Symptoms

  • Bleeding
    • Repeated rectal bleeding without obvious anal cause
    • Blood mixed in stool
  • Bowel Habit
    • Persistent change in bowel habit > 4 weeks
  • Mass
    • Unexplained abdominal mass
    • Palpable rectal mass
  • Pain
    • Abdo pain WITH weight loss
  • Anaemia
    • Unexplained, new IDA

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 >80 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
  • MDT Coordinator

Meeting Chair

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

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 the colorectal team. It is strongly encouraged that the clinician who has current responsibility for the patient's care attend the meeting to provide background information on the patient's fitness or personal wishes. However, the meeting Chair will present the case and 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. 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.

Discussing patients with outstanding results usually causes unnecessary re-discussion and increases workload. 

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.

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.

Abbreviations

Abdo: Abdominal
Age <75: Age less than 75 years
Age >80: Age greater than 80 years
CCE: Colon Capsule Endoscopy
CFS ≤3: Clinical Frailty Score less than or equal to 3
CFS >3: Clinical Frailty Score greater than 3
C-scope: Colonoscopy
CT: Computed Tomography
CTC: Computed Tomographic Colonography
DTT: Direct-to-Test
eGFR: Estimated Glomerular Filtration Rate
FBC: Full Blood Count
FIT <100: Faecal Immunochemical Test less than 100
FIT >20: Faecal Immunochemical Test greater than 20
Flexi-sig: Flexible Sigmoidoscopy
GI: Gastrointestinal
IDA: Iron Deficiency Anaemia
JUSC: Joint Urgent Suspected Cancer
MDT: Multidisciplinary Team
MRI: Magnetic Resonance Imaging
PA: Physician Associate
PMS: Patient Management System
USC: Urgent Suspected Cancer

Editorial Information

Last reviewed: 27/10/2025

Next review date: 27/10/2028

Author(s): Colorectal department .

Version: 2

Approved By: TAM subgroup of the ADTC

Reviewer name(s): C Richards, K Walker .

Document Id: TAM521