• Elizabeth Davies, Beverley van der Molen, and Amanda Cranston.
• Merton, Sutton and Wandsworth Health Authority, The Wilson, Mitcham, Surrey, UK. elizabeth.davies@kcl.ac.uk
• J Eval Clin Pract. 2007 Apr 1;13(2):310-7.

RationaleThere was local concern over possible delays in the diagnosis and referral of patients with suspected colorectal cancer and interest in understanding more about patients' experiences of diagnosis.Aims And ObjectivesTo use clinical audit, qualitative data from patients and feedback from general practitioners (GPs) to identify possible delays in referral, and to decrease these by implementing referral guidelines.MethodsAudit of endoscopy referrals assessed how often these recorded rectal examination and whether patients were seen within 2 weeks. Qualitative interviews with 19 patients explored their experience of referral and diagnosis. Review of 33 case records assessed other possible delays.ResultsMost patients referred for endoscopy were seen within 2 weeks (67%, 119/177), but only 47% (71/151) of available referral letters mentioned rectal examination. Patients perceived most delay in secondary care and case records suggested that this occurred after non-urgent referral. Patients also identified some problems with communication, information and support about the diagnosis. We used the results to stimulate local acceptance of national referral guidelines and wider discussion about care. A consultation exercise with GPs informed the development of a faxable urgent referral pro forma and supporting educational meetings. We designed a database to monitor changes in waiting times and made plans to improve communication and support after diagnosis.DiscussionFeeding back qualitative data from patients together with audit results seemed a powerful lever to stimulate action about hospital delays. Average waiting times dropped quickly and remained low due to the continuing national focus upon them. Seeking GP views may have promoted the use of referral pro formas, but monitoring waiting times distracted from a more thorough evaluation of their use. Qualitative data from patients raised awareness of their experience, but was time-consuming to collect and we had limited success in using it for specific initiatives around communication and support.

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