The West Midlands Cancer Alliance (WMCA) has led the development and approval of a new, regionally consistent pathway for patients with lower gastrointestinal symptoms who receive a negative faecal immunochemical test (FIT).
This clinically led redesign marks a significant step forward in ensuring patients receive the right care, in the right setting, at the right time, while protecting urgent cancer diagnostic capacity for those most at risk.
Why Change Was Needed
Lower GI urgent suspected cancer (USC) pathways across the NHS continue to experience sustained pressure, with demand far exceeding available diagnostic capacity. Despite strong national evidence demonstrating that patients with a FIT result below 10 µg Hb/g are at very low risk of colorectal cancer, a substantial proportion of these patients were still progressing through urgent cancer pathways across the West Midlands.
Baseline analysis showed that approximately 17% of LGI USC referrals and over 8% of colonoscopies were being undertaken in FIT‑negative patients, with significant variation between providers and Integrated Care Boards. While performance had improved since the introduction of an earlier FIT‑negative approach in 2023, progress had plateaued — highlighting the need for a more fundamental pathway redesign.
A Clinically Led, Collaborative Approach
The revised FIT‑negative pathway has been developed over a 12‑month period through extensive collaboration across primary care, secondary care and system partners. Work was led through the WMCA Lower GI Expert Advisory Group and a dedicated multidisciplinary LGI Operational Group, bringing together colorectal surgeons, gastroenterologists, primary care cancer leads, clinical nurse specialists, non‑specific symptoms leads and patient representatives.
All provider trusts across the West Midlands contributed to alliance‑wide triage and FIT‑negative surveys, helping define what “good” looks like in the management of FIT‑negative patients. Patient advocates were actively involved in discussions, ensuring reassurance, communication and safety‑netting were central to pathway design.
Safety, Consistency and Patient Experience
The new pathway moves beyond a binary cancer / non‑cancer model. It embeds:
This ensures that patients at very low risk are not exposed to unnecessary invasive investigations or prolonged periods of anxiety, while those at higher risk can access urgent diagnostics more quickly.
For the first time, a single, evidence‑based FIT‑negative framework is now available for use across all six Integrated Care Boards, reducing unwarranted variation and ensuring patients receive the same high standard of care regardless of where they live.
National Assurance and Future Readiness
The pathway has undergone extensive assurance, including engagement with national NHS England programme teams and senior clinical experts. Input was provided by NHS England advisors, academic leaders in gastroenterology, and authors of the BSG/ACPGBI FIT guidelines, ensuring alignment with national guidance and evolving best practice.
The model has been designed to remain relevant as national strategies continue to evolve, including the rollout of FIT@80 and the introduction of ColoFIT risk stratification. By focusing on principles rather than a static process, the pathway provides a sustainable framework capable of adapting to future diagnostic innovation.
What This Means for Patients
For patients across the West Midlands, this work means:
Next Steps
The pathway was formally ratified through WMCA clinical governance in April 2026 and went live for regional implementation from 27 April 2026. WMCA is now supporting local adoption through clinical engagement, implementation workshops and ongoing performance monitoring to ensure benefits are realised safely and transparently.
This work demonstrates what can be achieved when clinicians and system partners work together with a shared commitment to patient safety, equity and sustainability — delivering smarter pathways that improve care for patients across the West Midlands.