Editorial
Embracing news ways of working to reduce costs and improve care for patients with IBS
Radical service improves outcomes for patients with IBS in primary care Like many new ideas within the NHS, success relies heavily on a mixture of collaboration, grit determination and timing. This was very much the case with the Somerset dietetic-led gastroenterology clinic, which was established in 2012. The seeds of this idea started in 2010 at a time of deepening financial crisis within the NHS. The ‘silver lining’ was a resulting desire to support innovation that could save the NHS money while improving patient care. In the same year, King’s College London trained its first 10 UK dietitians in the newly emerging and highly successful diet for irritable bowel syndrome (IBS), the low FODMAP diet. I was lucky enough to be one of those first 10 dietitians. IBS treatment had been notoriously unsuccessful with UK IBS annual cost projections ranging from £45.6 to £200 million per year. In 2008, the National Institute for Health and Care Excellence (NICE,
2008) recognised an urgent need to reduce the number of expensive, unnecessary diagnostic tests for IBS and to educate GPs away from seeing IBS as a diagnosis of exclusion. Early referral to a dietitian was recommended, and with the low FODMAP diet, dietitians now had the tools to make a difference — making IBS treatment perfectly positioned for a radical rethink. In 2010–2011, the success of dietary intervention with IBS patients in South Somerset GP practices was assessed showing a 69% success rate. This evaluation coincided with a local gastroenterology secondary care audit by Dr Emma Greig, consultant gastroenterologist, Musgrove Park Hospital. Her audit showed that 14.3% of referrals from GPs were for non-red flag IBS patients under the age of 45, and that these unnecessary referrals were costing £161,198 per annum. It was clear that GPs needed an alternative referral option and that access to dietary intervention could be the ideal solution. Hence, in 2011, a collaborative group was established, Flexible Healthcare Somerset Gastroenterology Clinical Team, including members from secondary care, primary care, the Somerset Clinical Commissioning Group (CCG) and community dietetics (Somerset Partnership NHS Trust). Together, a proposal/business case was built with the aim of reducing unnecessary secondary care referrals/
Marianne Williams, NHS and private specialist allergy and irritable bowel syndrome (IBS) dietitian ?? GPN 2018, Vol 4, No 4
investigations and using the saved money to fund an alternative treatment pathway, which includes: An innovative, communitybased specialist dietetic-led gastroenterology clinic for non-red flag intractable IBS patients who have failed to respond to first-line dietary advice in general clinic. This was the first such service of its kind in the UK, creating a new role within the NHS, the specialist gastroenterology community dietitian. This service is available only to GPs and communitybased healthcare professionals, such as general practice nurses [GPNs] and uses dietary therapies, such as the low FODMAP diet, to provide effective symptom self-management for patients and avoid unnecessary secondary care referrals and invasive, costly investigations GP and GPN education to improve knowledge and skills within general practice in establishing the diagnosis and improving management of patients with likely IBS. Achieving this aim required a series of teaching sessions for GPs and GPNs around the county. The whole process was formalised with the creation of two innovative navigator pathway apps for GP desktops across Somerset, ‘The Diagnosis of Irritable Bowel Syndrome in Primary Care’, and, ‘The Management of Irritable Bowel Syndrome in Primary Care’ Non-invasive stool test (faecal calprotectin) to rule out inflammatory pathology in patients aged between 16 and 45 years in primary care, with no red flag symptoms who would otherwise be referred to secondary care due to patient request or GP/GPN anxiety about missing pathology. If the
faecal calprotectin was less than 50, the GP could refer to the community dietetics service for triaging into either general clinic or the new specialist dietetic-led gastroenterology clinic. In June 2012, the Somerset CCG funded a countywide service at the cost of £58,853. This funding included faecal calprotectin tests, 0.2 whole time equivalent administrator support, 15% on costs and a full-time band 6 specialist dietitian to run a county-wide, dietetic-led primary care gastroenterology service seeing adult patients with IBS. In 2014 a repeat gastroenterology audit by Dr Greig showed a 36% reduction in unnecessary referrals from GPs with total numbers dropping from 14.3% to 8.7%. This resulted in a 25% saving over baseline compared with costs from 2011. Meanwhile, dietetic outcomes in 2016 (n=335) showed that 74% of patients had improved quality of life with all IBS symptoms, such as abdominal pain, urgency, bloating and wind, showing statistically significant improvement (P<0.001) following dietary intervention. The Somerset IBS pathway went on to win the prestigious UK NICE Shared Learning Award in 2016. But, there is always room for more innovation. The world is changing at a fast rate. Technology is changing the way we work, play and seek health care. The key is to embrace new disruptive technology and make it solve old problems. In Somerset, the problems of too many patients, limited man hours and a large rural geographical area are being addressed with the use of new specialist first-line advice IBS ‘webinars’. Outcome data from the first 15 months of running the IBS webinars shows that after watching the webinar 78% of patients had For information on how to run webinars for patients, see: www.youtube.com/watch?v=neeP DS0mA24&list=PLA2JFuWGRVa 9zkiOW9in2oQA2cH6aTGMX
Marianne Williams (left) and ????? (right), winners of the ‘AHP Digital Practice Award’. improved confidence in managing their condition, while 96% stated that they would recommend the webinar to friends. Interestingly, the largest cohort of patients attending the webinars were the 65–74 year olds, showing that age is not a barrier to technology-based education. We have now run webinars for the low FODMAP diet, newly diagnosed coeliac disease and are presently preparing one for inflammatory bowel disease in remission. The local paediatric team have recorded one for fussy eaters and weaning on a milk and soya free diet. Any healthcare professional or patient is welcome to access these webinars — simply mail: patient.webinars@nhs.net and a registration link will be sent.
for work with transforming patient education. These IBS webinars have been showcased by NHS England in their recent document, Transforming gastroenterology elective care services.
This year our work with the webinars won the national award from NHS Digital and NHS England, ‘The AHP Digital Practice Award’ and I was privileged to win the ‘NHS England AHP of the Year Award’
NHS England (2017) Transforming gastroenterology elective care services. Available online: www.england. nhs.uk/publication/transforminggastroenterology-elective-care-services/
We plan to publish data and grow the use of webinars for a number of conditions over the next few years and look at the use of patient podcasts which is a growing area of public demand. GPN
References National Institute for Health and Care Excellence (2008) Irritable Bowel Syndrome: Costing report implementing NICE guidance. CG61. NICE, Manchester
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