IBS innovation helping to put patients in control of their health in the digital age

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/

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