Why is it important?
Good joined-up care only happens when GPs and specialists share timely and appropriate information about their IBD patients. This should include treatment and management details. IBD Nurse Specialists play a key role in facilitating good coordination between primary and secondary care through all stages of a patient’s journey with IBD – from diagnosis through to ongoing care and monitoring.
To underpin this coordinated care, it’s essential to have a secure system for sharing information about test results or treatment changes. This should be managed through IT, written communication between the GP and hospital, or patient-held records (or a combination of these as appropriate).
Required information in correspondence from secondary to primary care includes:
- Main diagnosis/diagnoses, specifying type and location of IBD and date of diagnosis
- Date(s) of surgery
- Secondary diagnosis/diagnoses e.g. anaemia/vitamin D deficiency/osteoporosis/ extraintestinal manifestations
- Date of last endoscopy with findings and date of next planned/routine endoscopy
- Date of next planned contact with secondary care
- Current medical therapy including any previous treatments with thiopurines, methotrexate or biologics and reasons for discontinuation
- Recommended length of current medical therapy
- Treatment recommendations in case of a flare – mesalazine/prednisolone/budesonide/calcium and vitamin D and who to contact if treatment is initiated in primary care
- Contact details for the IBD team/service
- RCGP IBD Toolkit for further advice and guidance for primary care.
All correspondence should be copied to patients, and/or parents/carers, and recorded in the patient’s care plan.