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Right person, right place, first time Transforming gastroenterology elective care services Case studies
Equality and health inequalities
About these case studies
Promoting equality and addressing health inequalities characteristic (as cited under the Equality Act 2010) and
Intervention summary are at the heart of our values. Throughout the those who do not share it; and Given regard to the need
Part 1: development of the policies and processes cited in this to reduce inequalities between patients in access to, and
Elective care 100 day document, we have: Given due regard to the need to outcomes from healthcare services and to ensure services
challenge programme – eliminate discrimination, harassment and victimisation, are provided in an integrated way where this might
Stockport case studies to advance equality of opportunity, and to foster good reduce health inequalities.
Part 2: relations between people who share a relevant protected
Elective care 100 day
challenge programme –
Somerset case studies
Information governance
Part 3:
Further case studies
and resources Organisations need to be mindful of the need to comply
with the Data Protection Act 1998, the Common Law
Duty of Confidence and Human Rights Act 1998 (Article 8
– right to family life and privacy).
Elective care transformation
Transformation of the GP referral and outpatient process
to give a better experience for patients and clinicians and
to make better use of resources. Patients should be seen
by the right person, in the right place, first time.
This information can be made available in alternative formats, such as easy read or large print, and may be available
in alternative languages, upon request. Please email england.electivecare@nhs.net
2 Right person, right place, first time
Contents click to return to this page (1)
About these case studies
Intervention summary
About these case studies 5
Part 1:
Intervention summary 6
Elective care 100 day Part 1: Elective care 100 day challenge programme – Stockport case studies 7
challenge programme –
Stockport case studies Local context 8
Part 2: Transforming IBD care in Stockport: Overview 9
Elective care 100 day
challenge programme – Transforming IBD care in Stockport: Detail 11
Somerset case studies
Implementing a NAFLD pathway in Stockport: Overview 12
Part 3:
Further case studies Implementing a NAFLD pathway in Stockport: Detail 13
and resources
Part 2: Elective care 100 day challenge programme – Somerset case studies 15
Local context 16
Rethinking abdominal symptoms referrals: Overview 17
Implementing an abdominal symptoms pathway: Detail 19
Standard referral template – abdominal symptoms: Detail 22
Advice and guidance via consultant connect: Detail 23
Strengthening digital self-management support: Overview 24
Digital self-management and monitoring for IBD and coeliac disease: Detail 25
IBS self-management webinars: Detail 27
Transforming gastroenterology outpatient care: Overview 29
Telephone follow ups for IBD: Detail 30
Condition-level clinical coding for outpatients: Detail 31
3 Right person, right place, first time
Contents click to return to this page (2)
About these case studies
Intervention summary
Part 3: Further case studies and resources 32
Part 1:
Selected further gastroenterology case studies 33
Elective care 100 day
Selected further elective care case studies 34
challenge programme –
Stockport case studies Further resources 35
Part 2:
Elective care 100 day
challenge programme –
Somerset case studies
Part 3:
Further case studies
and resources
4 Right person, right place, first timeAbout these case studies
About these case studies
Intervention summary
Objectives How to use these case studies
Part 1: Timely access to high quality elective care is a key These case studies are aimed at commissioners and
Elective care 100 day priority for both NHS England and local health and care healthcare providers. They provide examples of
challenge programme – systems, as set out in the NHS Constitution. Yet the NHS innovation in the delivery of elective care services and
Stockport case studies is experiencing unprecedented and growing demand for should be used alongside NHS England’s gastroenterology
Part 2: elective care. handbook, which sets out practical steps for
Elective care 100 day implementing key interventions in gastroenterology.
This case study pack was developed by NHS England’s
challenge programme –
Somerset case studies
Elective Care Transformation Programme. It provides The pack is split into three parts:
practical, evidence-based advice on delivering high •
Parts one and two list case studies from NHS England’s
Part 3: quality care for people using gastroenterology elective
Further case studies 100 day challenge programme. These interventions
care services, in the context of rapidly rising demand. were implemented at pace and show significant early
and resources
Its aim is to support commissioners and providers to work promise, but have not been subject to long-term
together to: evaluation. As such, the data presented is primarily
focused on process rather than outcomes.
•
Better manage rising demand for elective care services
• Part three showcases selected further case studies
• Improve patient experience and access to care
and resources to support innovation in the delivery of
•
Provide more integrated, person-centred care. gastroenterology elective care services.
Timely access to high These case studies provide
quality elective care is a practical advice on delivering
key priority for both NHS high quality care for people They should be used
England and local health using gastroenterology alongside NHS England’s
and care systems. However, elective care services. They gastroenterology handbook
demand for elective care are aimed at commissioners
is growing steeply. and providers.
5 Right person, right place, first timeIntervention summary
About these case studies
These case studies summarise:
Intervention summary
• Ten interventions tested within Wave 1 of the Elective • Overview of selected further case studies,
Part 1: Care Development Collaborative 100 day challenge including references to original documents
Elective care 100 day
challenge programme – Individual case studies are split into the three broad themes:
Stockport case studies
Part 2: Theme Somerset Stockport Other case studies
Elective care 100 day
• Implementing an abdominal • Transforming IBD
challenge programme –
Somerset case studies symptoms pathway care in Stockport (also
relevant to transforming
Part 3: Rethinking • Standard referral template –
outpatients)
Further case studies referrals abdominal symptoms
and resources • Implementing a NAFLD
• Advice and guidance via
pathway in Stockport
consultant connect
• Digital self-management • Digital self-management and nurse-
and monitoring for IBD and led monitoring for IBD (also relevant
Shared decision coeliac disease to transforming outpatients)
making & self- • IBS self-management
management webinars
support
• Telephone follow ups for IBD • Transforming IBD care in • “One-stop” nurse-led IBS clinics
Stockport (also relevant
• Condition-level clinical • Digital self-management and nurse-
Transforming to rethinking referrals)
coding for outpatients led monitoring for IBD (also relevant
outpatients to self-management support)
6 Right person, right place, first timePart 1
About these case studies
Intervention summary
Part 1:
Elective care 100 day
challenge programme
Elective care 100 day
challenge programme –
Stockport case studies
Part 2:
Elective care 100 day
challenge programme –
Somerset case studies Stockport case studies
Part 3:
Further case studies
and resources
7 Right person, right place, first timeLocal context
About these case studies
Intervention summary
The health and care system in Stockport Stockport gastroenterology rapid-testing team
Part 1: The Stockport system is part of the North of England The frontline team comprised the following
Elective care 100 day region of NHS England. As part of Stockport Together, a representatives:
challenge programme – vanguard programme, five health and care organisations
Stockport case studies are working together to transform care: NHS Stockport Administrative & clerical Clinicians
Part 2: Clinical Commissioning Group (with 41 GP practices);
Head of Business Consultant
Elective care 100 day Pennine Care NHS Foundation Trust (mental health
Development (Viaduct Gastroenterologist &
challenge programme – services); Stockport Metropolitan Borough Council;
Health) Hepatologist (Stepping Hill
Somerset case studies Stockport NHS Foundation Trust (Stepping Hill hospital
hospital)
Part 3:
and community health services); and Viaduct Care
Further case studies (a federation representing all Stockport GPs). Assistant Business Manager Liver Specialist Nurse
and resources (Stepping Hill hospital) (Stepping Hill hospital)
Gastroenterology pathway (liver project only)
Stockport’s specialist gastroenterology team is based at Senior Project Support IBD Specialist Nurse
Stepping Hill hospital. The multi-disciplinary team includes Officer (Viaduct Health & (Stepping Hill hospital) (IBD
consultants, nurse specialists, a dietitian, an IBD pharmacist Stockport Together) project only)
and a GP with a special interest in gastroenterology. Practice Manager (lead GP (lead GP for Heatons
Practice Manager for neighbourhood, Viaduct
Referrals are received from both general practice and
Heatons neighbourhood, Health)
within the hospital (consultant to consultant). All new
Viaduct Health)
patients are seen for an initial appointment with a
member of the specialist team and then directed for Project Manager (Stockport Practice Nurse (Heaton
further follow up and/or diagnostics as necessary. Council) Moor Medical Centre)
8 Right person, right place, first timeTransforming IBD care in Stockport: Overview
About these case studies
Intervention summary
The challenge
Part 1:
Stockport’s gastroenterology services were experiencing increasing referrals and follow up
Elective care 100 day appointments, resulting in long (18 week+) waiting times for many patients. The 100 day challenge
challenge programme – team* saw an opportunity to improve access to care for people with Inflammatory Bowel
Stockport case studies
Disease (IBD), while providing advice and guidance for GPs to help avoid unnecessary referrals.
Part 2:
Elective care 100 day
challenge programme – The interventions
Somerset case studies
IBD rapid access and ‘flare up’ clinics
Part 3:
Further case studies •
Opportunity: Reduce waiting times for people with • Results: No IBD baseline data was available, however
and resources suspected IBD and ensure people with IBD can quickly at the start of January 2017 the average RTT in
access care when they need it, rather than being gastroenterology was 13.7 weeks. For patients following
followed up at set timeframes. the new IBD pathway, the RTT had dropped to 8.8
•
Scope: Suspected new IBD cases and existing IBD patients weeks by June 2017, mainly due to quick access to an
accessing care at Stockport NHS Foundation Trust. initial appointment and referral for required tests.
•
Intervention tested: The model has two main
elements: *Stockport’s gastroenterology team took part in an NHS
1.
Rapid access clinic for suspected IBD cases, with England rapid-testing pilot in 2016: these interventions
patients booked into a clinic within approximately were established during this testing phase and have
two weeks. since been incorporated into business as usual.
2.
Flare up clinic: People with IBD are now given
less frequent follow ups but have direct access
to the IBD Specialist Nurse for telephone advice
when they need it, and if required can be brought
quickly into clinic for review.
9 Right person, right place, first timeTransforming IBD care in Stockport: Overview
About these case studies
Intervention summary
The interventions (continued)
Part 1: Consultant connect (advice and guidance)
Elective care 100 day
•
Opportunity: The team wanted to explore whether
challenge programme –
Stockport case studies direct access for GPs to an IBD specialist nurse
for advice and guidance, would help to reduce
Part 2: unnecessary referrals.
Elective care 100 day
challenge programme – •
Scope: Consultant Connect, a mobile telephone service
Somerset case studies that links GPs to consultants, was already up and
running in Stockport across various specialties, so the
Part 3:
Further case studies IBD nurses were added to this service.
and resources • Intervention tested: Direct access to specialist advice
and guidance for GPs via a mobile telephone service.
• esults: The evidence collected from a pilot across 8
R
specialties in Stockport indicates that around 40% of
referrals can be avoided by using Consultant Connect.
In gastroenterology, between July 2016 and March
2017, 48% of calls to the service avoided a referral.
The average talk time was 5 minutes, with 62% of
gastroenterology calls picked up.
For further information on Stockport’s
IBD work contact: Rachel Campbell,
rachel.campbell@stockport.nhs.uk
10 Right person, right place, first timeTransforming IBD care in Stockport: Detail
About these case studies
Intervention summary
The intervention
Part 1: Scope • The team’s assistant business manager established a
Elective care 100 day
• S uspected new IBD cases in Stockport are referred to dedicated email address and phone line for the clinic;
challenge programme –
a rapid access clinic at Stepping Hill hospital. Referrals this was much more complicated than anticipated due
Stockport case studies to local IT/procurement processes.
are sent directly to the IBD Specialist Nurse for
Part 2: triage; the patient is then booked into a clinic within • The pathway was tested and promoted at a GP
Elective care 100 day approximately two weeks. masterclass by the team’s GP lead; GP feedback
challenge programme –
Somerset case studies • S tockport GPs have telephone access to IBD specialist ensured it was easy to use.
nurses and gastroenterology consultants for advice Delivery
Part 3:
Further case studies and guidance.
• egular weekly appointment slots are held for people
R
and resources • eople with IBD are now given less frequent follow
P with flare-ups and suspected IBD.
ups but have direct access to the IBD Specialist Nurse
for telephone advice when they need it, and if • letter is sent to GPs who refer patients through
A
required can be brought quickly into clinic for review. the wrong pathway – indicating that the patient was
redirected to the correct pathway, and explaining why.
Planning and preparation • he pathway is being widely used, with positive
T
• The core 100 day challenge team comprised: a GP, feedback from people with IBD using clinic.
a practice manager, a consultant gastroenterologist
(IBD specialist), an IBD specialist nurse, an assistant
business manager (gastroenterology) and a GP
federation/CCG lead.
• The IBD specialist nurse played a key role in developing The outcome: No IBD baseline data was available,
and delivering clinics, although the involvement of all however at the start of January 2017 the average
team members was key in establishing a systems-level RTT in gastroenterology was 13.7 weeks. For
understanding of the challenge. patients following the new IBD pathway, the RTT
had dropped to 8.8 weeks by June 2017, mainly due
to quick access to an initial appointment and referral
for required tests.
11 Right person, right place, first timeImplementing a NAFLD pathway in Stockport: Overview
About these case studies
Intervention summary
The challenge
Part 1:
Stockport’s liver specialists reported that they were seeing a high number of people with
Elective care 100 day non-alcoholic fatty liver disease (NAFLD) who could be effectively managed in general
challenge programme – practice. This was limiting the specialist team’s ability to provide care for those in need of
Stockport case studies
their support. In response to this challenge, the 100 day challenge team has implemented a
Part 2:
Elective care 100 day
standard NAFLD pathway for GPs across Stockport.
challenge programme –
Somerset case studies The intervention
Part 3:
Further case studies Standardised pathway and referral template • The pathway follows NICE guidance and includes:
and resources • pportunity: Identify the right patients for referral to
O • Consultant Connect – a mobile telephone service
diagnostics in secondary care, reduce inappropriate that links GPs to liver consultants for advice and
referrals and reduce secondary care follow ups by guidance.
enabling effective management in the community – • A scoring system (NAFLD Score) that allows GPs to
thereby improving patient experience and outcomes. identify who should be referred.
• cope: Diagnosis and management of non-alcoholic
S • For those who need it, direct referral to a scan
fatty liver disease (NAFLD) across Stockport CCG. (fibroscan), where patients are risk-assessed.
• Intervention tested: A standardised referral pathway, • Signposting to relevant community resources,
including referral template, for non-alcoholic fatty such as healthy lifestyle support.
liver disease (NAFLD) across the CCG area, setting out
when, where and how people with or at risk of NAFLD Results: Referrals through the pathway are under evaluation.
should be referred – and who should be managed
within general practice.
For further information on Stockport’s NAFLD
work contact: Dr Kwashie AnimSomuah,
kwashie.animsomuah@stockport.nhs.uk
12 Right person, right place, first timeImplementing a NAFLD pathway in Stockport: Detail
About these case studies
Intervention summary
The intervention
Part 1: Scope Delivery
Elective care 100 day
• he standardised referral pathway provides clear
T • he pathway was promoted to GPs using various
T
challenge programme –
Stockport case studies guidance for GPs in Stockport as to when, where and methods – including a CCG email update (to GPs,
how to refer people with suspected NAFLD – and who practice nurses and practice managers), GP masterclass
Part 2: to manage within primary care. and through the CCG website.
Elective care 100 day
challenge programme – • he accompanying referral template helps to ensure a
T • he standardised referral template was uploaded to
T
Somerset case studies standard level of detail is provided with referrals. EMIS for use across Stockport.
Part 3: Planning and preparation • he hospital is reviewing existing NAFLD patients to
T
Further case studies identify those who could be returned to primary care
and resources • he core 100 day challenge team met every two weeks
T with a management plan.
and included: GP, practice nurse, practice manager,
consultant gastroenterologist and hepatologist, nurse
specialist (hepatology), assistant business manager
(gastroenterology), GP federation/CCG senior lead.
• he pathway and template design was led by the
T
consultant and GP, drawing on NICE guidance.
• owever, input from other team members –
H
particularly hospital and practice managers – was
crucial (e.g. in ensuring the template was usable on
EMIS, and setting up an nhs.net email address for
direct referrals). The outcome: Referrals through the pathway are
under evaluation; the aim is to identify the right
• Reaching agreement on the detail of the pathway
patients for referral to diagnostics in secondary care,
was more time consuming than expected: face-to-face
reduce inappropriate referrals and reduce secondary
meetings attended by the consultant, GP and CCG lead
care follow ups by enabling effective management
helped the team to progress.
in the community – thereby improving patient
experience and outcomes.
13 Right person, right place, first timeStockport Non-Alcoholic Fatty Liver Disease (NAFLD) pathway
About these case studies (June 2017)
Intervention summary
Part 1: Incidental finding Persistently Risk factors for NAFLD
Elective care 100 day on USS abnormal LFTs (other • Obesity • Hypertension • Cardiovascular Disease
challenge programme – causes excluded) (especially central) • Dyslipidaemia • CKD, PVD
Stockport case studies • Diabetes or prediabetes
Consider actively screening for NAFLD (with score and USS) if people have had multiple
Part 2: risk factors from a young age
Elective care 100 day
challenge programme –
Somerset case studies Data gathering • LFTS -up to 80% may be normal • Exclude XS alcohol (>14units per • NAFLD score –found on electronic test
• USS – may be normal but will help week), drugs (only stop statins if LFTs requests search (also needs BMI, FBC
Part 3: double within 3m of statin) and HbA1c)
exclude other conditions
Further case studies • Assess other risk factors – above – lab will automatically request AST
• Hepatitis screen if LFTs are abnormal –
and resources and calculate score
to exclude other causes
NAFLD score -1.455 ALT or AST >2x normal
if advice needed at any stage
Consider refer to liver team
Management in primary care Use performa (attached) and directly email to
• Manage hypertension, lipids • Lifestyle advice re obesity, snt-tr.liverspecialistnurses@nhs.net
and diabetes as appropriate prediabetes and alcohol Patients will then be considered for a fibroscan to assess
for fibrosis and steatosis.
Monitoring – (if has abnormal LFTs or USS or ongoing risk factors)
• Risk factors • LFTs minimum • USS
(as appropriate) every 2 years every 2 years Reassuring fibroscan More advanced disease:
Will be offered a liver biopsy
Resources and possible treatments
Discharged back to primary
PARIS / Life Leisure exercise 0161 4820900 care with individualised plan (pioglitazone, vitamin E)
START all aspects healthy lifestyle 0161 4743141 for monitoring and monitoring in secondary
care until more stable
TPA motivational & social support 0161 474 1042
PWS emotional support www.stockportpws.org.uk 0161 480 2020
In the future hopefully group education sessions will be available in the community via Minority may
TPA and START need transplant
14 Right person, right place, first timePart 2
About these case studies
Intervention summary
Part 1:
Elective care 100 day
challenge programme
Elective care 100 day
challenge programme –
Stockport case studies
art 2:
P
Elective care 100 day
challenge programme –
Somerset case studies Somerset case studies
Part 3:
Further case studies
and resources
15 Right person, right place, first timeLocal context
About these case studies
Intervention summary
The health and care system in Somerset Somerset gastroenterology rapid-testing team
Part 1: The Somerset system is in the South of England region The frontline team comprised the following representatives:
Elective care 100 day of NHS England. In this programme, NHS England has
challenge programme – worked with: Administrative & clerical Clinicians
Stockport case studies
• Yeovil District Hospital FT (YDH) Business Manager – Internal 2 Consultant
art 2:
P Medicine (YDH) Gastroenterologists
Elective care 100 day
• NHS Somerset Clinical Commissioning Group, covering
71 GP practices (SCCG) (YDH)
challenge programme –
Somerset case studies • Somerset Partnership NHS Trust (SP) Project Manager (YDH) 1 GP (Castle Cary
Part 3:
Surgery)
• 71 GP practices
Further case studies Transformation Programme 1 IBD Nurse Specialist
and resources Manager (SCCG) (YDH)
Gastroenterology Pathway
Operational Manager – Long- 1 Chief Pharmacist
Somerset’s specialist gastroenterology team is based term Conditions and Internal (YDH)
at Yeovil District hospital. The multi-disciplinary Medicine (YDH)
team includes consultants, nurse specialists, dietitian,
pharmacist and a GP with a special interest in Quality Improvement Lead (YDH) Community Dietician
gastroenterology. (SP)
Referrals are received from both general practice and Business Analyst (YDH)
within the hospital (consultant to consultant). All new Programme Management Office
patients are seen for an initial appointment with a Support Officer (YDH)
member of the specialist team and then directed for
further follow up and/or diagnostics as necessary. Programme Management Office
Support Officer (YDH)
16 Right person, right place, first timeRethinking abdominal symptoms referrals: Overview
About these case studies
Intervention summary
The challenge
Part 1:
Somerset’s specialist team reported that they were seeing a number of people in secondary
Elective care 100 day care that could be effectively managed in general practice with the right support –
challenge programme – particularly people with Irritable Bowel Syndrome (IBS). In response, they decided to
Stockport case studies
implement a standard pathway and referral template for people with abdominal symptoms,
art 2:
P
Elective care 100 day
while providing specialist advice and guidance for GPs to help avoid unnecessary referrals.
challenge programme –
Somerset case studies The intervention
Part 3:
Further case studies Abdominal symptoms pathway Referral results template
and resources • Opportunity: Identify the right patients for referral to •
Opportunity: To reduce inappropriate referrals coming
secondary care, reduce inappropriate referrals and to specialist services and improve the quality of
enable effective management of IBS in the community referral information.
– thereby improving patient experience and outcomes. •
Scope: All abdominal symptoms referrals. The
• cope: Diagnosis and management of IBS across
S template is designed to ensure the secondary care
Somerset CCG. consultant has all the relevant information, including
• Intervention tested: A standardised referral pathway blood test results, to make a decision at a patient’s
for people with abdominal symptoms, which supports first appointment.
primary care practitioners to diagnose and manage • I ntervention tested: The template was drafted by a GP
IBS, and provides clear guidance as to when to refer and a consultant who sought feedback from a wider
people with abdominal symptoms to secondary care. group of health professionals. It is available on EMIS
• Results: The pathway has been promoted to 71 GP with fields pre-populated by the system. The template
practices in Somerset, with referrals through the is attached to the electronic referral on ERS.
pathway under evaluation. •
Results: By day 100, 10% of all abdominal referrals
were being made using the template. Initial feedback
from consultants and GPs has been positive and the
uptake of the referral form continues to grow week
on week.
17 Right person, right place, first timeRethinking abdominal symptoms referrals: Overview
About these case studies
Intervention summary
The intervention (continued)
Part 1: Advice and guidance for GPs
Elective care 100 day
• Opportunity: Reduce unnecessary referrals and
challenge programme –
Stockport case studies support patient management in primary care through
specialist advice to GPs from consultants.
art 2:
P
Elective care 100 day • Scope: The service is designed to ensure GPs have
challenge programme – access to specialist support so they can effectively
Somerset case studies manage patients in primary care and avoid
unnecessary referrals into secondary care.
Part 3:
Further case studies • Intervention tested: The service was already running
and resources in Somerset across other specialties. The team adapted
this for gastroenterology and worked with primary
care to raise awareness.
• Results: As of day 100, 13 calls from GPs had been
received, with a referral avoided in 54% of calls.
For further information contact: Dr James Gotto,
james.gotto@ydh.nhs.uk
18 Right person, right place, first timeImplementing an abdominal symptoms pathway: Detail
About these case studies
Intervention summary
The intervention
Part 1: Scope • Access to dietitian services in the community
Elective care 100 day
• The pathway supports primary care teams to diagnose is offered to support effective management in
challenge programme –
and manage IBS, and provides clear guidance as to primary care, including self-management support
Stockport case studies and IBS webinars.
when to refer people with abdominal symptoms to
art 2:
P secondary care. Delivery
Elective care 100 day
challenge programme – •
It builds additional self-management support into the • The pathway was promoted to practice teams,
Somerset case studies pathway to allow more patients to be managed in including through a CCG and LMC newsletter to all
primary care. Somerset practices (GPs, practice managers and
Part 3:
Further case studies •
The pathway is currently available on the Navigator practice nurses) and via all letters from the hospital
and resources system, a GP patient management tool, and is being gastroenterology team to GPs.
introduced across all 71 GP practices in Somerset. • It is supported by a standard referral template
Planning and preparation to standardise the quality of information provided
with referrals.
• The pathway changes were developed by a dietitian,
two consultants, and a GP in several planning sessions.
Other gastroenterology consultants across Somerset
provided input at specific points of its development.
• The team modified an inactive pathway by changing
key information:
• F or consistency with the latest NICE guidance for
IBS, the latest Rome Criteria (2016) were used for
GPs’ first assessment.
• Faecal calprotectin testing is used to support
GPs to risk assess and make referral decisions, as The outcome: The pathway has been promoted to
recommended by NICE. all GP practices in Somerset, with referrals through
the pathway under evaluation.
19 Right person, right place, first timeSomerset diagnosis of IBS pathway (May 2017)
About these case studies
Primary care practitioner takes history and performs assessment ROME IV CRITERIA (2016)
Intervention summary
Recurrent abdominal pain, on average,
Part 1: Patient aged 16–45 presenting with symptoms consistent with IBS at least 1 day/week in the last 3 months,
Elective care 100 day (consider Rome criteria) associated with two or more of the
following criteria:
challenge programme –
• Related to defecation
Stockport case studies Any alarm symptoms signs? • Associated with change in
art 2:
P • Blood in stool frequency of Stool
Elective care 100 day • Unintentional or unexplained weight loss • Associated with a change in
challenge programme – • Nocturnal symptoms form (appearance) of stool
YES
Somerset case studies • Anaemia Criteria fulfilled for the last 3 months
OR Significant family history of bowel (or ovarian) cancer with symptom onset at least 6 months
Part 3: before diagnosis.
Further case studies NO
Please also see NICE Guidance for IBS
and resources updated April 2017
SUSPECTED INFLAMMATORY OR www.nice.org.uk/guidance/cg61
DIAGNOSIS OF IBS
OTHER PATHOLOGY
Fast track or Measure faecal calprotectin (see NOTE:
routine referral to box below) along with “chronic Faecal calprotectin testing should only be
gastroenterology diarrhoea bloods” CRP, LFT, U&E, undertaken where a referral to secondary
depending upon FBC, Coeliac screen, TSH, folate, care with a suspicion of inflammatory or
symptoms/history. ferritin, B12, calcium, albumin other pathology is being considered
and stool culture if diarrhoea
Non-urgent referral
to gastroenterology. YES NO Manage in primary care
Please make FC FC>150
according to NICE IBS guidelines
result and symptoms
clear in referral
letter
If FC 50–150 repeat test in 6–8
weeks and use basic lifestyle
measures in meantime. If repeat
If FC negative, consider FC >150 or if FC level higher at Move to separate pathway
non-GI pathology if clinical repeat test then for non-urgent – Management of IBS in
concern remains referral to gastroenterology primary care
20 Right person, right place, first timeSomerset management of IBS pathway: Pages 1 and 2 (May 2017)
About these case studies
Intervention summary
Management of irritable bowel syndrome in primary care
Part 1:
Patient diagnosed with IBS and no alarm symptoms OR referred to
Elective care 100 day
GP by secondary care for dietary advice
challenge programme – Positive YES
Stockport case studies Discharge
response?
art 2:
P GP to take blood tests for “chronic diarrhoea bloods”, CRP, LFT, U&E,
Elective care 100 day FBC, Coeliac screen, TSH, folate, ferritin, B12, calcium, albumin and NO
challenge programme – stool culture if diarrhoea
Somerset case studies
Refer back to GP to consider medication and further tests
Part 3: In cases of constipation or alternating bowel habit, use laxatives (e.g.
Further case studies Refer to secondary Laxido 1-2 sachets per day) For diarrhoea try loperamide (2-8 mg/day).
care as appropriate
and resources YES For pain-predominant disease consider neuromodulator or SSRI e.g.
Abnormal This may include
bloods? amitriptyline (10 mg/night)
referral for duodenal
biopsies if coeliac
serology is positive
NO
YES
Refer to primary care community dietetic services for first line dietary Responsive? Discharge
management of IBS for 2 months at dieteticsreferrals@sompar.nhs.uk
NO
YES GP referral to secondary care gastroenterology as appropriate
Responsive? Discharge
NO
If patient fails to respond then they can complete self referral form for
specialist community dietetic-led gastroenterology clinic for dietetic
intervention including the low FODMAP diet
21 Right person, right place, first timeStandard referral template – abdominal symptoms: Detail
About these case studies
Intervention summary
The challenge
Part 1:
Somerset’s specialist team reported variation in the quality of referrals for abdominal
Elective care 100 day symptoms, with some patients being referred without relevant test results. While
challenge programme – implementing an abdominal symptoms pathway, the 100 day challenge team identified an
Stockport case studies
opportunity to introduce a standard referral template to improve and standardise the quality
art 2:
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Elective care 100 day
of information provided with abdominal symptoms referrals.
challenge programme –
Somerset case studies The intervention
Part 3:
Further case studies Scope • The following information is included:
and resources • The standard referral template is used by GPs in • Patient demographics
Somerset for all abdominal symptoms referrals. • Referrer details
• It is available on EMIS with fields pre-populated by the • Medical history and previous diagnoses
system. The template is attached to the electronic
referral on ERS. • Specific blood investigation results
Planning and preparation Delivery
• The template was developed by primary care leads, • The final electronic version of the template
with input from secondary care over a number of drafts. incorporates GP feedback, making it an easy-to-use
tool with automatic pop-up and pre-population of
• The template includes a defined group of blood appropriate fields
tests specified by secondary care in order to facilitate
diagnosis earlier in the patient pathway. The group
has been included in the electronic pathology ordering
The outcome: By day 100, 10% of all abdominal
system in primary care for consistency and ease of use.
referrals were being made using the template. Initial
• The team based the form on other standard referral feedback from consultants and GPs has been positive
forms across Somerset to ensure a degree of and the uptake of the referral form continues to
consistency across the county. grow week on week.
22 Right person, right place, first timeAdvice and guidance via consultant connect: Detail
About these case studies
Intervention summary
The challenge
Part 1:
Somerset’s specialist gastroenterology team reported that they were seeing a number of
Elective care 100 day people who, with the right support, could have been managed in primary care. The team
challenge programme – sought to test whether a telephone-based advice and guidance service, where GPs have the
Stockport case studies
option to contact consultants for specialist advice, would support effective management in
art 2:
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Elective care 100 day
primary care and reduce inappropriate referrals.
challenge programme –
Somerset case studies The intervention
Part 3:
Further case studies Scope Delivery
and resources • The service is used by GPs to access telephone advice • The team identified that GP uptake was key to the
from a specialist, in order to reduce inappropriate success of this intervention; the pathway was emailed
referrals and manage patients more effectively in to all GP practices via a CCG bulletin.
primary care. • Consultant Connect went live on 3 April 2017 and as of
• onsultant Connect, the platform selected by the
C 3 July 13 calls had been made to the service:
team, is in use across all 71 GP practices in Somerset. • The average call wait was 52 seconds
• Four gastroenterology consultants at Yeovil District • The average call duration was 4 minutes 23 seconds
Hospital are available during working hours to provide
advice to GPs over the phone, with a recording stored
of each call.
Planning and preparation
• Consultant Connect was selected as it was already used
in other specialties and could be easily transferred to
gastroenterology.
• A gastroenterology consultant, with support from a The outcome: As of day 100, 13 calls from GPs had
business manager, developed a rota to ensure there been received, with a referral avoided in 54% of calls.
was always a specialist available to answer calls.
23 Right person, right place, first timeStrengthening digital self-management support: Overview
About these case studies
Intervention summary
The challenge
Part 1:
The team in Somerset identified that people with IBS, IBD and coeliac disease
Elective care 100 day would benefit from improved access to self-management support to help
challenge programme – them manage their long-term condition effectively, achieve a better quality
Stockport case studies
of life and avoid complications. In response, they have introduced two
art 2:
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Elective care 100 day
innovative digital self-management support options.
challenge programme –
Somerset case studies The intervention
Part 3:
Further case studies Digital self-management and monitoring manage, with the aim of reducing the frequency and
and resources •
Opportunity: To increase the quality of information intensity of IBS symptoms.
available to patients and practitioners through a digital •
Scope: The webinar is available to people with IBS in
tool, enabling improved communication, monitoring of Somerset and provides direct access to a dietitian.
health status, and direct access to a patient-controlled • I ntervention tested: Patients were either referred into
health record and digital self-management resources. the webinar through a dietitian as part of a first-line
• cope: The platform will be available to primary
S advice offer, were referred by their GP or self-referred.
care, secondary care and community services across •
Results: 74% (29 of 39) of the invited patients
Somerset. It will initially be used by IBD patients, and attended two pilot webinars. After the second
then expanded to people with coeliac disease. webinar, 6 of 9 (67%) participants reported being
•
Intervention tested: Patients Know Best, a digital moderately confident in managing their IBS
self-management tool which has been successfully symptoms, as opposed to 0 before the webinar.
introduced across other parts of the country.
•
Results: With the funding agreed, the implementation For further information on Patients Know Best contact:
team aim to have the system live and being used by Julie Thomas, julie.thomas@ydh.nhs.uk
patients before the end of 2017. and Dr James Gotto, james.gotto@ydh.nhs.uk
IBS self-management webinars For further information on IBS webinars contact:
• pportunity: A webinar to support people with IBS
O Marianne Williams, marianne@wisediet.co.uk
to understand their condition and effectively self-
24 Right person, right place, first timeDigital self-management and monitoring
About these case studies for IBD and coeliac disease: Detail
Intervention summary
Part 1: The challenge
Elective care 100 day
challenge programme – The team in Somerset identified that people with IBD and coeliac disease would
Stockport case studies benefit from improved access to self-management and self-monitoring support
art 2:
P to help them manage their condition effectively, achieve a better quality of
Elective care 100 day life and access medical support before problems occur or escalate. In response,
challenge programme –
Somerset case studies they have introduced Patients Know Best, an innovative online portal.
Part 3:
Further case studies The intervention
and resources
Scope Planning and preparation
• atients Know Best is an online portal that allows
P • Multiple digital providers were initially asked to
people to access and control their medical records, present. Patients Know Best was chosen based on its
monitor their symptoms, decide when to access care user-friendly interface, interoperability with EMIS/
and get information on how to self-manage. external apps, and positive outcomes achieved in other
• The system also enables the specialist team to monitor similar health systems, such as Luton and Dunstable.
their patients remotely: the details of anyone scoring • The team’s consultant led on engagement with IT and
low are passed to a workload sheet so clinical staff can IG managers to discuss the information governance
make contact with them accordingly. and security implications.
• The platform will be initially made available for all • Based on capacity, the IT manager recommended a
patients with IBD, and will then be expanded to all phased implementation approach starting with IBD.
coeliac patients in Somerset.
• It was due to integrate with EMIS later in 2017,
making it more easily accessible for GPs.
25 Right person, right place, first timeDigital self-management and monitoring
About these case studies for IBD and coeliac disease: Detail
Intervention summary
Part 1: The intervention (continued)
Elective care 100 day
challenge programme – Delivery
Stockport case studies
• Business case approval took 65 days. Commenting
art 2:
P on the pace of approval, the Business Manager said:
Elective care 100 day “usually approval of a business case takes up to six
challenge programme – months, however this process has proved that with the
Somerset case studies
right clinical and managerial support, key decisions
Part 3: can be made in a far more timely manner.”
Further case studies
and resources
The outcome: At the time this collection went to press,
the system had not yet gone live. It aims to ensure
patients access support when they need it, reduce
inappropriate outpatient appointments, and
improve self-management capacity and quality of life.
26 Right person, right place, first timeIBS self-management webinars: Detail
About these case studies
Intervention summary
The challenge
Part 1:
The team in Somerset identified that people with IBS would benefit from
Elective care 100 day improved access to self-management support in order to reduce the frequency
challenge programme – and intensity of IBS symptoms and improve their quality of life. In response,
Stockport case studies
they introduced a dietitian-led webinar for people with IBS.
art 2:
P
Elective care 100 day
challenge programme – The intervention
Somerset case studies
Scope • The team ran an initial pilot webinar for a preselected
Part 3:
• The dietitian-led webinar is a 90 minute session aimed group of people to test the technology and format of
Further case studies
and resources at supporting people with IBS to develop the skills and the sessions.
confidence to self-manage their condition. • The webinars have been integrated into the IBS
referral pathway and promoted to local clinicians,
Planning and preparation including through: LMC and CCG newsletters to
• The team adapted a successful webinar approach GPs, GP study day and meetings and the bulletin to
from a local mental health team (using GoToWebinar community pharmacists.
software). • Flyers are also distributed directly to people with
• The content and structure of the webinar was IBS at hospital appointments, GP practices, dietetics
developed by the team’s lead dietitian, with input and pharmacies.
from the GP and consultants, to meet the following
objectives:
• Provide patients with direct, personalised and
convenient access to a dietitian (remotely, and
outside of working hours).
• Develop a supportive, anonymous environment
where no question is off limits.
27 Right person, right place, first timeIBS self-management webinars: Detail
About these case studies
Intervention summary
The challenge
Part 1:
The team in Somerset identified that people with IBS would benefit from
Elective care 100 day improved access to self-management support in order to reduce the frequency
challenge programme – and intensity of IBS symptoms and improve their quality of life. In response,
Stockport case studies
they introduced a dietitian-led webinar for people with IBS.
art 2:
P
Elective care 100 day
challenge programme – The intervention (continued)
Somerset case studies
Delivery
Part 3: The outcome: 74% (29 of 39) of patients who
Further case studies • The 90 minute session is delivered by two dietitians
were invited attended one of the two pilot
and resources – one of whom leads the session, while the other
webinars. After the second webinar, 6 of 9 (67%)
answers confidential questions from attendees via the
participants reported being moderately confident
webinar instant messaging tool.
in managing their IBS symptoms, as opposed to
• Patients can self-refer, or be referred into the webinar 0 before the webinar.
either through a dietitian as part of a first-line advice
offer or through their GP.
• The following feedback was received from attendees:
• “Being able to ask questions to the dietitian….
no travel required…getting access to accurate &
reliable information.”
• “I really enjoyed it! Very informative and a great
idea that we could all take part without having to
take time out of our jobs. Brilliant idea.”
28 Right person, right place, first timeTransforming gastroenterology outpatient care: Overview
About these case studies
Intervention summary
The challenge
Part 1:
The team in Somerset identified that some people with Inflammatory Bowel
Elective care 100 day Disease (IBD) were being brought into the hospital for unnecessary face-to-face
challenge programme – follow ups. Meanwhile, a lack of condition-level data across gastroenterology
Stockport case studies
outpatients made it difficult to plan and monitor service improvement
art 2:
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Elective care 100 day
initiatives. As a result, the team decided to test telephone follow up for IBD
challenge programme – and implement condition-level clinical coding across the specialty.
Somerset case studies
Part 3: The interventions
Further case studies
and resources Telephone follow ups for IBD than simply specialty-level), thereby supporting service
•
Opportunity: To conduct follow ups for people with improvement and planning.
IBD without complications via telephone, making • Scope: Data has initially been collected by one
access to care easier and more flexible for patients. consultant; the intention is to expand to all
•
Scope: All IBD patients without complications. The gastroenterology outpatient appointments at Yeovil
patient proceeds to a face-to-face appointment if District Hospital.
required. • I ntervention tested: Diagnosis and condition coded for
•
Intervention tested: Specialist nurse-led telephone each outpatient appointment. The intention is also to
follow ups for people with IBD without complications. understand appointment-to-diagnosis rates for specific
cohorts of patients.
•
Results: By July 2017, 20 telephone follow ups had
been delivered. Patients reported increased satisfaction •
Results: Condition-level gastroenterology data at
with telephone appointments, as they are more Yeovil District Hospital is now available for a single
convenient and avoid the need for a hospital visit. consultant’s clinic.
Further outcomes data is under evaluation.
Clinical coding for outpatients For further information contact: Dr James Gotto,
•
Opportunity: Improve gastroenterology outpatients james.gotto@ydh.nhs.uk
data by coding attendances at condition-level (rather
29 Right person, right place, first timeTelephone follow ups for IBD: Detail
About these case studies
Intervention summary
The challenge
Part 1:
The IBD specialist nurse recognised that not all Inflammatory Bowel Disease
Elective care 100 day (IBD) patients in a stable condition need to be assessed in person for routine
challenge programme – follow ups, resulting in avoidable hospital visits for patients and taking up
Stockport case studies
clinical time unnecessarily. As a result, the team decided to trial telephone
art 2:
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Elective care 100 day
follow up appointments.
challenge programme –
Somerset case studies The interventions
Part 3:
Further case studies Scope • The IBD nurse delivers the appointment at the
and resources • Telephone follow ups are offered to IBD patients without same time as the previously scheduled face-to-face
complications accessing care at Yeovil District Hospital. appointment.
• The aim is to limit the time spent on routine follow ups • Over the 100 day testing period the IBD nurse
and eliminate the need for patients to come to hospital. delivered 20 telephone follow up appointments, with
a further 100 patients identified as eligible and moved
• The patient proceeds to a face-to-face appointment if onto telephone follow up.
required.
• The IBD nurse was positive about the new approach to
Planning and preparation follow ups, stating that: “Patients have reported that
• The service was developed in secondary care by the IBD follow ups over the phone are convenient and save
specialist nurse and operational manager. time and money coming to the hospital”. A survey has
been distributed to participating patients to gather
• A private room with a telephone was procured by the further feedback.
operational manager to allow for patient confidentiality
when the IBD nurse delivers the appointment.
The outcome: Patients report increased satisfaction
Delivery with telephone appointments, as they are more
• Fortnightly, the IBD nurse examines a list of clinic convenient and avoid the need for a hospital visit.
appointments six weeks in advance and selects Further outcomes data is under evaluation.
patients eligible for telephone follow ups.
30 Right person, right place, first timeCondition-level clinical coding for outpatients: Detail
About these case studies
Intervention summary
The challenge
Part 1:
The team identified a need to improve gastroenterology outpatient data, in
Elective care 100 day order to understand the number of appointments at condition level and monitor
challenge programme – the impact of service change initiatives. The team was unable to identify this
Stockport case studies
data in primary care and the Trust only coded for elective inpatients. A consultant
art 2:
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Elective care 100 day
gastroenterologist worked to develop an approach to coding outpatients.
challenge programme –
Somerset case studies The interventions
Part 3:
Further case studies Scope • As a time-consuming process, this cannot be replicated
and resources •
Improve gastroenterology outpatients data by across all consultants so the lead consultant is working
coding attendances at condition-level (rather than with analytical colleagues to automate the process on
simply specialty-level), thereby supporting service the hospital system (TrakCare) and create a more visual
improvement and planning. format.
•
Data has initially been collected by one consultant; • Other aims include adding co-morbidities and
the intention is to expand to all gastroenterology appointment-to-diagnosis rates.
outpatient appointments at Yeovil District Hospital. Delivery
•
The intention is also to understand appointment-to- • The consultant has been recording data on an
diagnosis rates for specific cohorts of patients at the ongoing basis since April 2017. The spreadsheet is
condition level. available internally within Yeovil District Hospital.
Planning and preparation
• The data was not available in primary care so the lead The outcome
consultant manually recorded data from each clinic on A spreadsheet showing all patients seen from April in
Condition a single consultant’s clinic is available internally within
Yeovil District Hospital, with plans in place to
Confirmed or working diagnosis.
automate the process on the hospital system.
31 Right person, right place, first timePart 3
About these case studies
Intervention summary
Part 1:
Further case studies
and resources
Elective care 100 day
challenge programme –
Stockport case studies
Part 2:
Elective care 100 day
challenge programme –
Somerset case studies
Part 3:
Further case studies
and resources
32 Right person, right place, first timeSelected further gastroenterology case studies
About these case studies
Intervention summary Case study Findings Source
Part 1: “One-stop” • A small scale trial shows potential for specialist nurse-led IBS clinics in Neilson M, Caulfield L, Morris
Elective care 100 day nurse-led IBS secondary care to reduce waiting times for consultant clinics. AJ, Gaya D, Winter J, Cahill A,
challenge programme – clinics Lachlan N, Stanley AJ, Forrest
• It found that appropriately trained IBS specialist nurses are able to
Stockport case studies E, Gillespie R, Barclay S, Smith
confirm diagnosis of IBS, effectively manage patients and facilitate
LA (2017). ‘Initial experience
Part 2: discharge back to primary care.
Elective care 100 day of a nurse-led irritable bowel
challenge programme – syndrome clinic’. Gut, vol
Somerset case studies 66 (Suppl 2). gut.bmj.com/
content/66/Suppl_2/A91.2
Part 3:
Further case studies Digital self- • In 2012, Luton and Dunstable Hospital implemented Patients Know Johnson MW, Lithgo K, Price
and resources management Best (PKB) for stable IBD patients, an online portal that supports T (2014). ‘The First Year’s
and nurse-led self-management (for further detail on PKB see also page 29). Outcome Data From UK’s
monitoring for First Remote Web-based self-
• The team aimed to transfer the care of stable IBD patients from
IBD management Programme For
hospital-based outpatient appointments, to community-based
Stable Inflammatory Bowel
monitoring and management, co-ordinated by a specialist IBD nurse.
Disease Patients’. Gut, vol
• Data from the first year of use indicated that the new model of 63 (Suppl 2). gut.bmj.com/
care was effective, safe and cost efficient, reducing outpatient content/63/Suppl_1/A231.1
waiting times and receiving positive feedback from patients.
Gastroenterology • In response to rapidly increasing referrals to gastroenterology Pelitari S, Hathaway C, Gritton
outpatient secondary care services, Royal Wolverhampton NHS Trust (RWT) has D, Smith A, Bush D, McKaig
referral clinical introduced a “Clinical Assessment Service” triage system B (2017). ‘Impact and cost
assessment for gastroenterology. effectiveness of formal
service gastroenterology outpatient
• This service enables the specialist team to triage GP referrals to the
referral clinical assessment
most appropriate pathway.
service’. Gut, vol 66 (Suppl
• Three years of data show that 32% of patients triaged through the 2). gut.bmj.com/content/66/
Clinical Assessment Service were discharged to primary care with Suppl_2/A8.1
advice and without the need for an appointment in secondary care
– saving approximately £331,000.
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