What is a colonoscopy?

Following a positive bowel screening result, a General Practitioner (GP) will refer a patient to have a colonoscopy for further investigation. During the procedure, a doctor will insert a narrow flexible tube with a tiny camera into the bowel to look for polyps or cancerous growths. 

For more information visit this helpful link.

Ways to access a colonoscopy in NSW

There are three main pathways a patient can take to access a colonoscopy in NSW. The pathway they take will affect:

• how they are assessed prior to the procedure (in person or over the phone)
• the out-of-pocket costs associated with the pre-colonoscopy assessment and the colonoscopy itself
• the time they will need to wait to have their colonoscopy.

It is important for patients to be fully informed of the options available to them. They should also be informed of financial or other implications prior to being referred. Click here for information on facilitating informed financial consent.

Following a positive bowel screening result, a GP will refer a patient to:

1. 1. The Direct Access Colonoscopy (DAC) service of a public hospital 
   Most patients will be assessed over the phone prior to the day of the colonoscopy. There will be no out-of-pocket costs to the patient for either the pre-colonoscopy consultation or the procedure itself. More details below.
2. 2. The outpatient gastroenterology clinic of a public hospital
3. The patient will need to attend the hospital in person to be assessed prior to the day of the colonoscopy. There will be no out-of-pocket costs to the patient for the pre-colonoscopy consultation or the procedure itself if the colonoscopy is then done in a public hospital.
4. 3. A private specialist’s (gastroenterologist or colorectal surgeon) rooms
   The patient will typically need to be seen in person to be assessed prior to the colonoscopy which often incurs an out-of-pocket cost. 

This page focuses on option 1 (Direct Access Colonoscopy).

What is Direct Access Colonoscopy (DAC) and what are the benefits?

DAC is a NSW Health Leading Better Value Care initiative that focuses on helping people gain access to public colonoscopy services after a bowel cancer screening test. This test is known as an immunochemical Faecal Occult Blood Test or iFOBT.

A key advantage of DAC is that it allows otherwise healthy patients, who have a positive iFOBT to be assessed and triaged during a free telephone appointment with a trained nurse. This is an alternative to having a face-to-face appointment with a specialist prior to the day of the colonoscopy.

The benefits of this service are that it:

• removes the wait for a public outpatient consultation, for suitable patients
• allows direct booking to colonoscopy
• frees up clinic time for patients with more complex issues. 

If patients are suitable for telephone assessment, they will only need to come to the hospital once for their actual procedure.  

DAC services improve access to colonoscopy for people in NSW by reducing barriers commonly faced by patients, such as: 

• extended wait times for clinic appointments
• unnecessary face to face appointments
• the need to take time off work
• time spent travelling to specialists/outpatient appointments
• out-of-pocket costs for private specialist room appointments.

 

Direct access pathway for positive iFOBT

 

Information for primary care providers

Why should I refer my patients to DAC?

A DAC service aims to mitigate the impact of the common barriers faced by patients by allowing clinically eligible patients to be assessed over the telephone by a Clinical Nurse Consultant. A nurse-led telephone triage assessment enables patients meeting the inclusion criteria (see below) to be referred directly to a DAC service, whilst also allowing specialist clinic time to be directed to more complex patients.  DAC services have a well-structured and protocolised triage and assessment pathway which assures safe, independent assessment by nursing staff with specialist oversight.

DAC is a beneficial option for clinically eligible patients, leading to:

• The earlier detection of bowel cancer which should lead to a lower incidence of bowel cancer and reduced morbidity and mortality for patients.
• Improved access to public colonoscopy, especially in areas without an existing outpatient clinic.
• Improved wait times for colonoscopy resulting from the removal of the wait for a face-to-face pre-colonoscopy clinic appointment.
• Reduced anxiety and psychological distress (resultant from lengthy waiting periods).
• For public hospitals and specialists, a reduction in low-value clinic activity (redirecting patients who do not need to be seen in person to DAC assessment) and therefore increasing the service’s capacity to focus on more complex cases.
• Reduced out of pocket costs and travel time for patients.

What if the patient doesn’t meet the referral criteria for the triage in a DAC service, or if they aren’t able to be triaged by telephone? 

They will need to make a face-to-face appointment in clinic with a specialist before their colonoscopy.

 

Who is eligible to be referred to a DAC service and how do I refer to DAC?

Each DAC service has developed their own clinical criteria specific to their local circumstances and population, however, in general the referral criteria requires a patient aged 45-75 years to have returned a positive iFOBT, be asymptomatic and otherwise healthy. 

For more information of eligibility, consider using Refer4Scope, an online decision tool to support assessment, triage, and referral for colonoscopy services by primary care practitioners.

Refer to the table below to be directed to your local HealthPathways colonoscopy information page for region-specific eligibility criteria and referral information. 

If you do not use HealthPathways, please refer to the ‘alternative referral contact details’ column below.

Referral documentation inclusions

For all colonoscopy referrals, it is crucial that primary care providers include sufficient information for the receiving clinician to assess the appropriateness, risk and urgency of consultation. Comprehensive referrals prevent delays and allow accurate assessment of the patient’s suitability for colonoscopy and for DAC.

Whilst each DAC service has developed their own clinical criteria specific to their local circumstances and population (see HealthPathways links in the table below), in general, colonoscopy referrals should include the following information:

• Indication for the referral including bowel symptoms, iFOBT results and/or family history of colorectal cancer (age of diagnosis of first-degree relatives).
• Relevant medical history, including cardiorespiratory disease, diabetes, abdominal and pelvic surgery. Note: Recent blood testing results should be limited to what's relevant to the decision about colonoscopy.
• Current medicines including anti-coagulants, diabetic and weight loss medications.
• Results of previous investigations, including iFOBT (indicating whether this was through the NBCSP and include participant ID), colonoscopies and histopathology.

Locations and referral information

There are many established DAC services across NSW. Most Local Health Districts (LHDs) have at least one operational DAC service. Please see the map and table below to find your nearest available DAC service. 

*These services book to a number of hospitals in their region. See full list of hospitals in table below.

 

 

DAC model of care

The DAC model of care (PDF) provides guidance for the localised implementation of direct access services across NSW. The model of care outlines the mandatory and recommended inclusions for implementation and should be read in conjunction with the following:

• the Australian Commission on Safety and Quality in Health Care Colonoscopy Clinical Care Standard 2018
• the National Safety and Quality Health Service Standards
• the National Health and Medical Research Council (NHMRC) Clinical Practice Guidelines for Surveillance Colonoscopy
• local LHD and SHN policies and procedures.

In 2024, the model of care was revised to ensure accuracy and to incorporate any changes to practice since the model was first published in 2020. 

 

DAC evaluation

In 2024 the Cancer Institute is conducting an evaluation of DAC services, including:

• Analysis of linked administrative data
• Economic evaluation
• Surveys and interviews with clinicians
• Patient-reported experience measures (PREM) survey
   

Primary care and participant resources

Flyers

• GP information flyer - Fast-tracking your patient to colonoscopy (PDF)
• Participant information flyer - Following up on your positive result (PDF)

Refer4Scope – Colonoscopy Referral Decision Tool

• Refer4Scope, co-designed by the Daffodil Centre with clinicians, is a decision tool for primary care to support clinical assessment and referral of patients requiring a colonoscopy based on colorectal cancer screening outcomes, bowel-related symptoms and/or family history of colorectal cancer. 
• During a patient consult, GPs can follow the quick and easy prompts to input their patient’s information and receive clinically-accurate recommendations in moments.
• Refer4Scope was developed by leading experts and co-designed with clinicians. It draws from the 2023 update to the 'Clinical Practice Guidelines for the prevention, early detection and management of colorectal cancer'.