Transforming gastroenterology - Case studies - NHS ...

 
Transforming gastroenterology - Case studies - NHS ...
Right person, right place, first time

Transforming
gastroenterology
elective care services

Case studies
Transforming gastroenterology - Case studies - NHS ...
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

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Transforming gastroenterology - Case studies - NHS ...
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

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Transforming gastroenterology - Case studies - NHS ...
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 time
About 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 time
Intervention 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 time
Part 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 time
Local 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 time
Transforming 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 time
Transforming 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 time
Transforming 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 time
Implementing 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 time
Implementing 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 time
Stockport 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 time
Part 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 time
Local 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 time
Rethinking 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 time
Rethinking 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 time
Implementing 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 time
Somerset 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 time
Somerset 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 time
Standard 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:
P
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 time
Advice 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:
P
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 time
Strengthening 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:
P
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 time
Digital 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 time
Digital 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 time
IBS 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 time
IBS 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 time
Transforming 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:
P
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 time
Telephone 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:
P
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 time
Condition-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:
P
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 time
Part 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 time
Selected 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.
 33                                                                                                              Right person, right place, first time
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