"Closed books": restrictions to primary healthcare access in Aotearoa New Zealand-reporting results from a survey across general practices.

AIM: In Aotearoa New Zealand, primary care is organised by enrolling patients with a primary care provider. However, the benefits of this arrangement are frustrated when providers "close their books" due to insufficient capacity for new patients. We investigated the extent, evolution and impact of this situation on health access and equity in access to primary healthcare. METHOD: We distributed a survey for general practice personnel in 2022, yielding 227 valid responses. We examined responses across respondents' practice characteristics, including practice size, rural-urban setting, average co-payments, region and ethnic composition of the catchment population. RESULTS: Most general practices are selectively enrolling their patients. In 2022, only 28% of respondents freely enrolled new people. Since 2019, most respondents (79%) had "closed books" or limited enrolments at some point. The situation worsened between 2019 and 2022, compromising equal opportunity and access in healthcare. CONCLUSION: Restricted enrolment poses a widespread barrier to health access and equity, and it worsened since the beginning of the COVID-19 pandemic. Addressing closed books and limited enrolments in general practice could significantly improve health services' access and equity. The study aims to inform ongoing health reforms.

Financial barriers to primary health care in Aotearoa New Zealand.

BACKGROUND: In Aotearoa New Zealand, co-payments to see a general practitioner (GP, family doctor) or collect a prescription are payable by virtually all adults. OBJECTIVE: To examine the extent to which these user co-payments are a barrier to accessing health care, focussing on inequities for indigenous Maori. METHODS: Pooled data from sequential waves (years) of the New Zealand Health Survey, 2011/12 to 2018/19 were analysed. Outcomes were self-reported cost barriers to seeing a GP or collecting a prescription in the previous year. Logistic regression was used to estimate odds ratios (ORs) of barriers to care for Maori compared with non-Maori, sequentially adjusting for additional explanatory variables. RESULTS: Pooled data included 107,231 people, 22,292 (21%) were Maori. Across all years, 22% of Maori (13% non-Maori) experienced a cost barrier to seeing a GP, and 14% of Maori (5% non-Maori) reported a cost barrier to collecting a prescription. The age- and wave-adjusted OR comparing Maori/non-Maori was 1.71 (95% confidence interval [CI]: 1.61, 1.81) for the cost barrier to primary care and 2.97 (95% CI: 2.75, 3.20) for the cost barrier to collecting prescriptions. Sociodemographics accounted for about half the inequity for both outcomes; in a fully adjusted model, age, sex, low income, and poorer underlying health were determinants of both outcomes, and deprivation was additionally associated with the cost barrier to collecting a prescription but not to seeing a GP. CONCLUSIONS: Maori experience considerable inequity in access to primary health care; evidence supports an urgent need for change to system funding to eliminate financial barriers to care.

Cohort profile: Nga Kawekawe o Mate Korona | Impacts of COVID-19 in Aotearoa - a prospective, national cohort study of people with COVID-19 in New Zealand.

PURPOSE: The COVID-19 pandemic has had significant health, social and economic impacts around the world. We established a national, population-based longitudinal cohort to investigate the immediate and longer-term physical, psychological and economic impacts of COVID-19 on affected people in Aotearoa New Zealand (Aotearoa), with the resulting evidence to assist in designing appropriate health and well-being services for people with COVID-19. PARTICIPANTS: All people residing in Aotearoa aged 16 years or over, who had a confirmed or probable diagnosis of COVID-19 prior to December 2021, were invited to participate. Those living in dementia units were excluded. Participation involved taking part in one or more of four online surveys and/or in-depth interviews. The first wave of data collection took place from February to June 2022. FINDINGS TO DATE: By 30 November 2021, of 8735 people in Aotearoa aged 16+ who had COVID-19, 8712 were eligible for the study and 8012 had valid addresses so were able to be contacted to take part. A total of 990 people, including 161 Tangata Whenua (Maori, Indigenous peoples of Aotearoa) completed one or more surveys; in addition, 62 took part in in-depth interviews. Two hundred and seventeen people (20%) reported symptoms consistent with long COVID. Key areas of adverse impacts were experiences of stigma, mental distress, poor experiences of health services and barriers to healthcare, each being significantly more pronounced among disabled people and/or those with long COVID. FUTURE PLANS: Further data collection is planned to follow-up cohort participants. This cohort will be supplemented by the inclusion of a cohort of people with long COVID following Omicron infection. Future follow-ups will assess longitudinal changes to health and well-being impacts, including mental health, social, workplace/education and economic impacts of COVID-19.

An area-based description of closed books in general practices in Aotearoa New Zealand.

Introduction In Aotearoa New Zealand, patients can enrol in a general practice for their primary health care. When a general practice no longer enrols new patients this is known as 'closed books'. We examined which District Health Board (DHB) districts were most affected and what characteristics of general practices and DHB districts were associated with closed books. Methods Maps were used to display the distribution of closed books general practices. Linear regression and logistic regression were used to look at the association between DHB or general practice characteristics and closed books. Results There were 347 (33%) general practices that had closed books in June 2022. Canterbury DHB (n = 45) and Southern DHB (n = 32) had the greatest number of closed books general practices, while Wairarapa DHB (86%), Midcentral DHB (81%) and Taranaki DHB (81%) had the greatest percentage. Consultation fees (P Conclusion The problem of closed books is felt across the country but has a larger impact in the middle-lower North Island. This influences access to primary health care enrolment for patients in terms of travel distance, time, and cost. Consultation fees were strongly associated with closed books. This suggests there may be an income threshold above which general practices can afford to close their books if they reach capacity.

Association between enrolment with a Primary Health Care provider and amenable mortality: A national population-based analysis in Aotearoa New Zealand.

INTRODUCTION: In Aotearoa New Zealand, being enrolled with a Primary Health Care (PHC) provider furnishes opportunities for lower cost access to PHC, preventative care and secondary health care services, and provides better continuity of care. We examine the characteristics of populations not enrolled, and whether enrolment is associated with amenable mortality. METHOD: We retrieved records of all deaths registered 2008 to 2017 in Aotearoa New Zealand, which included demographic and primary cause of death information. Deaths were classified as premature (aged under 75 years) or not, and amenable to health care intervention or not. The Primary Health Organisation (PHO) Enrolment Collection dataset provided the PHC enrolment status. Logistic regression was used to estimate the risk of amenable deaths by PHO enrolment status, adjusted for the effects of age, sex, ethnicity and deprivation. RESULTS: A total of 308,628 mortality records were available. Of these, 38.2% were premature deaths, and among them 47.8% were amenable deaths. Cardiovascular diseases made up almost half of the amenable deaths. Males, youths aged 15-24 years, Pacific peoples, Maori and those living in the most socio-economically deprived areas demonstrated a higher risk of amenable mortality compared to their respective reference category. One in twenty (4.3%) people who had died had no active enrolment status in any of the calendar years in the study. The adjusted odds of amenable mortality among those not enrolled in a PHO was 39% higher than those enrolled [Odds Ratio = 1.39, 95% Confidence Interval 1.30-1.47]. IMPLICATIONS: Being enrolled in a PHC system is associated with a lower level of amenable mortality. Given demonstrated inequities in enrolment levels across age and ethnic groups, efforts to improve this could have significant benefits on health equity.

Improving health services for patients with extreme obesity requiring bariatric level care at Wellington Regional Hospital: a clinical audit.

AIM: To benchmark the quality of bariatric service delivery against moving and handling and patient care best practice standards, and determine the prevalence of hospitalised patients admitted to Wellington Regional Hospital requiring bariatric level care. METHODS: A clinical audit consisting of retrospective case-note review and cross-sectional survey was conducted and benchmarked against Accident Compensation Corporation (ACC) national standards. Information recorded included patient demographics, admission planning, patient anthropometric and risk assessments, provider communication, room preparation, mobilisation plan, equipment needs, space and facility design considerations, discharge planning and reportable events. RESULTS: A total of 574 patients were included. The prevalence of hospitalised patients requiring bariatric services was 6.4%. One third of patients (34.3%) were not identified by clinical teams as requiring bariatric support. Most bed (80%) and bathroom (83%) spaces failed to achieve the facility design standard. The majority of patient focused moving and handling hazards were documented whereas environmental hazards or equipment limitations were poorly reported. Only 26.1% of patients had a documented discharge plan. CONCLUSION: Inadequate identification of patients requiring bariatric support and insufficient documentation of bariatric service delivery were identified. Improving policy adherence will address shortcomings in the provision of a safe environment and high quality care for bariatric patients.

Healthcare Service Interventions to Improve the Healthcare Outcomes of Hospitalised Patients with Extreme Obesity: Protocol for an Evidence and Gap Map.

Hospitalised patients with extreme obesity have poorer healthcare outcomes compared to normal weight patients. How hospital services are coordinated and delivered to meet the care needs of patients with extreme obesity is not well understood. The aim of the proposed evidence gap map (EGM) is to identify and assess the available evidence on healthcare interventions to improve healthcare outcomes for hospitalised patients with extreme obesity. This research will use standardised evidence gap map methods to undertake a five-stage process to develop an intervention-outcome framework; identify the current evidence; critically appraise the quality of the evidence, extract, code, and summarise the data in relation to the EGM objectives; and create a visualisation map to present findings. This EGM will provide a means of determining the nature and quality of health service initiatives available, identify the components of the services delivered and the outcome measures used for evaluation, and will identify areas where there is a lack of research that validates the funding of new research studies.

Consequences of barriers to primary health care for children in Aotearoa New Zealand.

Inequities in the provision of accessible primary health care contribute to poor health outcomes and health inequity. This study evaluated inequities in the prevalence and consequences of barriers that children face in seeing a general practitioner (GP) in Aotearoa New Zealand. We analysed data on 5,947 children from the Growing Up in New Zealand longitudinal study cohort on barriers to seeing a GP in the previous year, reported by mothers when their children were aged 24 months and 54 months (in 2011/12 and 2013/14 respectively); and maternal-reported hospitalisations in the year prior to age 54 months. We used logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CIs) for consequences of these barriers. Overall, 4.7% (n = 279) of children experienced barriers to seeing a GP in the year to 24 months and 5.5% (n = 325) in the year to 54 months. At each age, and for each specific barrier studied, barriers were more prevalent among Maori (the indigenous people of Aotearoa New Zealand), and among Pacific, compared to New Zealand European, children. Children facing barriers in the year to age 24 months were twice as likely to be hospitalised in the year to 54 months (OR 2.18, 95%CI: 1.38 to 3.44). When this relationship was analysed by ethnicity, the association was strongest for Maori (OR: 2.92, 95%CI: 1.60 to 5.30), less strong for Pacific (OR 2.01, 95%CI: 0.92 to 4.37) and not present for New Zealand European (OR 1.27, 95%CI 0.39 to 4.12) families. Barriers that children face to seeing a GP have social and cost implications for families and the health system. Changes to the health system, and future health policy, must align with the New Zealand government's obligations under Te Tiriti o [The Treaty of] Waitangi, to ensure that health equity becomes a reality for Maori.

Assessing need for primary care services: analysis of New Zealand Health Survey data.

Introduction The 2001 Primary Health Care Strategy provided significant new government funding for primary care (general practice and related services) via capitation funding formulas. However, there remain important unanswered questions about how capitation funding formulas should be redesigned to ensure equitable and sustainable service provision to all population groups. Aim To compare levels of chronic illness, utilisation, and unmet need in patients categorised as 'high-need' with those categorised as non-'high-need' using the definitions that are used in the current funding context, in order to inform primary care funding formula design. Methods Respondents of the New Zealand Health Survey (2018-19) were categorised into 'high-need' and non-'high-need', as defined in current funding formulas. We analysed: (i) presence, and number, of chronic diseases; (ii) self-reported primary care utilisation (previous 12 months); and (iii) self-reported unmet need for primary care (previous 12 months). Analyses used integrated survey weights to account for survey design. Results In total, 29% of respondents were 'high-need', of whom 50.2% reported one or more chronic conditions (vs 47.8% of non-'high-need' respondents). 'High-need' respondents were more likely than non-'high-need' respondents to: report three or more chronic conditions (14.4% vs 13.7%); visit a general practitioner more often (seven or more visits per year: 9.9% vs 6.6%); and report barriers to care. Discussion There is an urgent need for further quantification of the funding requirements of general practices serving high proportions of 'high-need' patients in order to ensure their viability, sustainability and the provision of quality of care.

The enrolment gap: who is not enrolling with primary health organizations in Aotearoa New Zealand and what are the implications? An exploration of 2015-2019 administrative data.

BACKGROUND: Primary Health Care (PHC) is the entry point to accessing health services in many countries. Having a high proportion of the population enrolled with a PHC provider is key to ensuring PHC fulfils this role and that it contributes to achieving better equity in health. We aimed to understand the extent to which people in Aotearoa New Zealand are enrolling with Primary Health Organizations (PHOs), how enrolment rates have evolved over time, and variations across District Health Boards (DHBs) and socio-demographic groups. METHODS: We analysed administrative data on the proportion of people enrolled in PHOs and breakdowns across DHBs, and by age, ethnicity and deprivation, for the years 2015-2019. RESULTS: About 6% of the population was not enrolled in 2019. There are persistent differences across socio-demographic groups as well as geographically. Maori have lower enrolment rates than New Zealand European/Other groups. Young people (15-24 years) are the least likely to be enrolled. The most affluent areas have the highest enrolment rates. Auckland DHB shows the lowest enrolment rates. CONCLUSIONS: Enrolments remain below full population coverage and inequities exist between socio-demographic and geographic groups. Potential reasons explaining these trends include methodological limitations as well as real issues in accessing services. We recommend (a) work towards minimising data issues in relation to this indicator to improve its accuracy and value in signalling trends in access to PHC services, and (b) investigating the reasons for the potential widening of the inequities identified, in particular issues preventing Maori and younger people from enrolling. This study deepens our understanding of enrolment rates as an indicator for tracking equity in PHC. Other countries can learn from the Aotearoa New Zealand case to draw lessons for improving equity in health care.

Equity in access to zero-fees and low-cost Primary Health Care in Aotearoa New Zealand: Results from repeated waves of the New Zealand Health Survey, 1996-2016.

Primary Health Care in Aotearoa New Zealand is mainly funded through capitation-based funding to general practices, supplemented by a user co-payment. Funding is designed in part to keep the costs of care low for key groups in the population who have higher health needs. We investigated changes in the socio-demographic determinants of no-cost and low-cost access to Primary Health Care using data from sequential waves of the New Zealand Health Survey (1996/97-2016/17). Fees paid were self-reported and inflated using CPI-adjustment to the value of the 2018NZD. Over the 20-year study period, there was an increase in the population accessing low-cost care. Access to low-cost care was particularly high for Pacific people, but also higher for Maori and Asian people compared to Other/New Zealand European ethnicities. Area-level deprivation was a stronger predictor of access to low-cost care for non-Maori than for Maori. Although Maori were more likely than non-Maori to access low-cost care at all levels of deprivation, this was less evident in more deprived compared to more affluent areas. Given ongoing reported inequity for Maori being less able to afford primary health care, we suggest that future policies to improve access should be fully aligned with the articles of Te Tiriti o Waitangi and should focus on equity.

Developing the WCRF International/University of Bristol Methodology for Identifying and Carrying Out Systematic Reviews of Mechanisms of Exposure-Cancer Associations.

Background: Human, animal, and cell experimental studies; human biomarker studies; and genetic studies complement epidemiologic findings and can offer insights into biological plausibility and pathways between exposure and disease, but methods for synthesizing such studies are lacking. We, therefore, developed a methodology for identifying mechanisms and carrying out systematic reviews of mechanistic studies that underpin exposure-cancer associations.Methods: A multidisciplinary team with expertise in informatics, statistics, epidemiology, systematic reviews, cancer biology, and nutrition was assembled. Five 1-day workshops were held to brainstorm ideas; in the intervening periods we carried out searches and applied our methods to a case study to test our ideas.Results: We have developed a two-stage framework, the first stage of which is designed to identify mechanisms underpinning a specific exposure-disease relationship; the second stage is a targeted systematic review of studies on a specific mechanism. As part of the methodology, we also developed an online tool for text mining for mechanism prioritization (TeMMPo) and a new graph for displaying related but heterogeneous data from epidemiologic studies (the Albatross plot).Conclusions: We have developed novel tools for identifying mechanisms and carrying out systematic reviews of mechanistic studies of exposure-disease relationships. In doing so, we have outlined how we have overcome the challenges that we faced and provided researchers with practical guides for conducting mechanistic systematic reviews.Impact: The aforementioned methodology and tools will allow potential mechanisms to be identified and the strength of the evidence underlying a particular mechanism to be assessed. Cancer Epidemiol Biomarkers Prev; 26(11); 1667-75. ©2017 AACR.

Post-diagnosis serum insulin-like growth factors in relation to dietary and lifestyle changes in the Prostate testing for cancer and Treatment (ProtecT) trial.

PURPOSE: The insulin-like growth factor (IGF) system is modifiable by diet and lifestyle, and has been linked to prostate cancer development and progression. METHODS: We conducted a prospective cohort study of 621 men diagnosed with localized prostate cancer to investigate the associations of dietary and lifestyle changes with post-diagnosis circulating levels of IGF-I and IGFBP-3. We used analysis of covariance to estimate the associations, controlling for baseline IGF-I or IGFBP-3, respectively. RESULTS: Mean IGF-I levels were 6.5% (95% CI -12.8, -0.3%, p = 0.04) lower in men who decreased their protein intake after diagnosis compared to men who did not change. Men who changed their fruit and vegetable intake had lower IGF-I levels compared to non-changers [Decreased intake: -10.1%, 95% CI -18.4, -1.8%, p = 0.02; Increased intake: -12.0%, 95% CI -18.4, -1.8%, p = 0.002]. IGFBP-3 was 14.6% (95% CI -24.5, -4.8%, p = 0.004) lower in men who achieved a healthy body mass index after diagnosis. Men who became inactive had 9.5% higher average IGF-I levels (95% CI 0.1, 18.9%, p = 0.05). CONCLUSIONS: Decreased protein intake and body mass index, and increased physical activity and fruit and vegetable intake, following a prostate cancer diagnosis were associated with reduced post-diagnosis serum IGF-I and IGFBP-3. Counterintuitively, reduced fruit and vegetable intake was also associated with reduced IGF-I, but with weak statistical support, possibly implicating chance. If confirmed in other studies, our findings may inform potential lifestyle interventions in prostate cancer. ProtecT was registered at International Standard Randomised Controlled Trial Registry, http://isrctn.org as ISRCTN20141297.

Does milk intake promote prostate cancer initiation or progression via effects on insulin-like growth factors (IGFs)? A systematic review and meta-analysis.

PURPOSE: To establish whether the association between milk intake and prostate cancer operates via the insulin-like growth factor (IGF) pathway (including IGF-I, IGF-II, IGFBP-1, IGFBP-2, and IGFBP-3). METHODS: Systematic review, collating data from all relevant studies examining associations of milk with IGF, and those examining associations of IGF with prostate cancer risk and progression. Data were extracted from experimental and observational studies conducted in either humans or animals, and analyzed using meta-analysis where possible, with summary data presented otherwise. RESULTS: One hundred and seventy-two studies met the inclusion criteria: 31 examining the milk-IGF relationship; 132 examining the IGF-prostate cancer relationship in humans; and 10 animal studies examining the IGF-prostate cancer relationship. There was moderate evidence that circulating IGF-I and IGFBP-3 increase with milk (and dairy protein) intake (an estimated standardized effect size of 0.10 SD increase in IGF-I and 0.05 SD in IGFBP-3 per 1 SD increase in milk intake). There was moderate evidence that prostate cancer risk increased with IGF-I (Random effects meta-analysis OR per SD increase in IGF-I 1.09; 95% CI 1.03, 1.16; n = 51 studies) and decreased with IGFBP-3 (OR 0.90; 0.83, 0.98; n = 39 studies), but not with other growth factors. The IGFBP-3 -202A/C single nucleotide polymorphism was positively associated with prostate cancer (pooled OR for A/C vs. AA = 1.22; 95% CI 0.84, 1.79; OR for C/C vs. AA = 1.51; 1.03, 2.21, n = 8 studies). No strong associations were observed for IGF-II, IGFBP-1 or IGFBP-2 with either milk intake or prostate cancer risk. There was little consistency within the data extracted from the small number of animal studies. There was additional evidence to suggest that the suppression of IGF-II can reduce tumor size, and contradictory evidence with regards to the effect of IGFBP-3 suppression on tumor progression. CONCLUSION: IGF-I is a potential mechanism underlying the observed associations between milk intake and prostate cancer risk.

Examining if being overweight really confers protection against dementia: Sixty-four year follow-up of participants in the Glasgow University alumni cohort study.

BACKGROUND: Recent large-scale studies suggest that obesity and overweight may confer protection against future dementia. This observation could, however, be generated by reverse causality. That is, weight loss in the incipient phase of dementia ascribed to diminished self-care, including sub-optimal nutrition, would have the effect of generating such an inverse association. One approach to circumventing this problem would be to measure weight in a population which is young enough to be free of the symptoms of dementia which is then followed up for dementia occurrence over many decades. METHODS: In a prospective cohort study, body mass index, and other potential risk factors, were measured in 9547 male university undergraduates (mean age 20.5 years) in 1948-68 who were then linked to national mortality registers. RESULTS: Of 2537 deaths over a mean of 50.6 years follow up, 140 were ascribed to dementia. There was no association between overweight and future dementia deaths (age-adjusted hazard ratio; 95 % confidence interval: 0.93; 0.49, 1.79). CONCLUSION: In this cohort study of former university students, being overweight in youth did not confer protection against later dementia death.

Pre-natal exposures and breast tissue composition: findings from a British pre-birth cohort of young women and a systematic review.

BACKGROUND: Breast density, the amount of fibroglandular tissue in the adult breast for a women's age and body mass index, is a strong biomarker of susceptibility to breast cancer, which may, like breast cancer risk itself, be influenced by events early in life. In the present study, we investigated the association between pre-natal exposures and breast tissue composition. METHODS: A sample of 500 young, nulliparous women (aged approximately 21 years) from a U.K. pre-birth cohort underwent a magnetic resonance imaging examination of their breasts to estimate percent water, a measure of the relative amount of fibroglandular tissue equivalent to mammographic percent density. Information on pre-natal exposures was collected throughout the mothers' pregnancy and shortly after delivery. Regression models were used to investigate associations between percent water and pre-natal exposures. Mediation analysis, and a systematic review and meta-analysis of the published literature, were also conducted. RESULTS: Adjusted percent water in young women was positively associated with maternal height (p for linear trend [p t] = 0.005), maternal mammographic density in middle age (p t = 0.018) and the participant's birth size (p t < 0.001 for birthweight). A 1-SD increment in weight (473 g), length (2.3 cm), head circumference (1.2 cm) and Ponderal Index (4.1 g/cm3) at birth were associated with 3 % (95 % CI 2-5 %), 2 % (95 % CI 0-3 %), 3 % (95 % CI 1-4 %) and 1 % (95 % CI 0-3 %), respectively, increases in mean adjusted percent water. The effect of maternal height on the participants' percent water was partly mediated through birth size, but there was little evidence that the effect of birthweight was primarily mediated via adult body size. The meta-analysis supported the study findings, with breast density being positively associated with birth size. CONCLUSIONS: These findings provide strong evidence of pre-natal influences on breast tissue composition. The positive association between birth size and relative amount of fibroglandular tissue indicates that breast density and breast cancer risk may share a common pre-natal origin.

Being overweight in early adulthood is associated with increased mortality in middle age.

Observational analyses of the association between body mass index (BMI) and all-cause mortality often suggest that overweight is neutral or beneficial, but such analyses are potentially confounded by smoking or by reverse causation. The use of BMI measured in early adulthood offers one means of reducing the latter problem. We used a cohort who were first measured while 16-24 year old students at Glasgow University in 1948-1968 and subsequently re-measured in 2000-2003, offering a rare opportunity to compare BMI measured at different ages as a predictor of mortality. Analysis of the later BMI measurements suggested that overweight was beneficial to survival, while analysis of BMI measured in early adulthood suggested that overweight was harmful and that the optimum BMI lay towards the lower end of the recommended range of 18.5-25 kg m-2. We interpret the association with later BMI as being probably distorted by reverse causality, although it remains possible instead that the optimum BMI increases with age. Differences when analyses were restricted to healthy non-smokers also suggested some residual confounding by smoking. These results suggest that analyses of BMI recorded in middle or old age probably over-estimate the optimum BMI for survival and should be treated with caution.

Rapid diagnostic pathways for suspected colorectal cancer: views of primary and secondary care clinicians on challenges and their potential solutions.

OBJECTIVES: To ascertain the challenges associated with implementation of the 2-week wait referral criteria and waiting time targets for colorectal cancer and to identify recommendations for improvements to the pathway. DESIGN: Qualitative research using semistructured interviews and applying thematic analysis using the method of constant comparison. SETTING: 10 primary care surgeries and 6 secondary care centres from 3 geographical areas in the England. PARTICIPANTS: Purposive sample of 24 clinicians (10 general practitioners (GPs), 7 oncologists and 7 colorectal surgeons). RESULTS: GPs and specialists highlighted delays in patient help-seeking, difficulties applying the colorectal cancer referral criteria due to their low predictive value, and concerns about the stringent application of targets because of potential impact on individual care and associated penalties for breaching. Promoting patient awareness and early presentation, clarifying predictive symptoms, allowing flexibility, optimising resources and maximising care coordination were suggested as improvements. CONCLUSIONS: Challenges during diagnosis and treatment persist, with guidelines and waiting time targets producing the perception of unintended harms at individual and organisational levels. This has led to variations in how guidelines are implemented. These require urgent evaluation, so that effective practices can be adopted more widely.