Mr. Paul Gordon:

We do a lot of work on colonoscopy and there is huge demand. It has increased over the past few years. I cannot necessarily put my finger on a specific cause of the problem, but we have seen a huge increase in the last number of years. What is required in that field is greater referral pathways. HIQA produced specific guidelines in relation to colonoscopy for general practitioners at the end of 2014. They were issued to consultants, but I do not think they have been followed up on with GPs or that any additional training has been provided. As I mentioned earlier, there are problems with referrals between hospital groups. What we would really like for patients is the right intervention for the right person at the right time. One could have a GP for whom the referral path and guidelines are not there. If someone presents with abdominal pain, he or she will send that patient on for a colonoscopy. However, there might be a better intervention available. That increases the pressure on the system. If GPs have people coming in repeatedly with similar symptoms and waiting longer and longer, he or she may refer a patient as an urgent case whereas that may not necessarily be what is required. That burden is there. It is very difficult for a consultant then to say that the person does not need that intervention, because it could cause huge difficulties down the line. Unfortunately, it is a cyclical thing.