A recent survey carried out by Crohn’s & Colitis UK and the Royal College of GPs¹ highlighted some of the difficulties faced by GPs in relation to referrals and the relationship with secondary care.

“Last time I referred someone with ‘query Crohn's’, it was a three month wait for an outpatient appointment.”

“Urgent gastro appointments are 26 weeks, for flare-ups or new patient diagnosis. IBD nurse slots for flare-ups do not exist anymore.”

For patients with suspected Inflammatory Bowel Disease, the NICE quality standard (QS81 2015) states that they should be seen for assessment within 4 weeks of referral to a specialist and the revised 2019 IBD Standards outline the need for clear protocols and the same timeframe for referrals.

However, there are huge pressures on resources and finances within secondary care. That is why we need to look towards those who have implemented new models and approaches such as Royal Wolverhampton NHS Trust.

Who's doing it well?

Between 2012-2013, a 25% increase in new outpatient gastroenterology referrals was observed at Royal Wolverhampton Trust in comparison to the preceding year. This increase in demand resulted in significant pressures, both financial and organisational, to meet national standards. This increase continues to rise year on year.

In response to pressures to meet national referral-to-treatment targets, Royal Wolverhampton NHS Trust and Wolverhampton Clinical Commissioning Group met to identify a more efficient and cost-effective way of managing outpatient services. This led to the development of the Clinical Assessment Service (CAS), whereby Consultant Gastroenterologists triage patients to the most appropriate pathway in a timely manner. The aims were to optimise secondary care resources and empower GPs to manage more patients in the community.

This was initially tested with a pilot study and then rolled out.

The idea

Previously gastrointestinal referrals to Royal Wolverhampton NHS Trust came via three routes - fast track two-week wait referrals, choose and book service or direct GP letters to the department. CAS was developed to allow secondary care gastroenterology clinicians to triage patients to the most appropriate pathway based on a ‘CAS proforma’.

In addition to streamlining pathways, the aim was to avoid inappropriate outpatient visits, improve efficiency and reduce expenditure. Both Royal Wolverhampton NHS Trust and the Clinical Commissioning Group were also keen to empower GPs to manage more gastrointestinal conditions in the community.

This change to the model was undertaken in a variety of stages. To ensure clinical care and patient safety was not compromised, Royal Wolverhampton NHS Trust undertook a blinded, retrospective audit of 300 gastrointestinal referrals. This also helped inform financial modelling for CAS proposals.

To make the model a success, bespoke IT needed to be created to allow for the establishment of a virtual clinic to fit the CAS proforma.

Financial arrangements then needed to be organised and the 18 other referring clinical commissioning groups in the area agreed to use the pathway.

The pilot study was analysed, and the number of consultant sessions required, the timeframe for review and the action of referrals was identified. The new system was given time to bed-in and GPs and patients were kept fully informed about the transition.

In terms of potential IBD referrals for new patients, there is now an established pathway used by all consultants who deliver CAS to streamline those patients with diarrhoea or rectal bleeding straight to the appropriate diagnostic test. This has enabled these patients to achieve a diagnosis and/or commence treatment in around 20 days on average.

Results

• Overall, 32% of CAS triaged patients were managed without a face to face gastroenterology consultation in outpatient clinic.
• This corresponds to 3,136 less outpatient appointments at Royal Wolverhampton Trust over the 3-year period, equating to 448 new outpatient clinics (as defined by British Society of Gastroenterology guidance).
• Based on current CAS capacity of 112 slots per week, 87 CAS sessions were required for review of all CAS referrals received. This equates to saving 361 clinic sessions.

Financial

• Using the number of patients not requiring an outpatient appointment, it is possible to calculate gross savings achieved.
• The formula used was [(Outpatient clinic tariff) – (CAS clinic tariff) X Number of outpatient appointments avoided].
• Over a 3-year period, it is estimated that a total of £481,613 was saved.

¹Crohn’s & Colitis UK and RCGP IBD Spotlight Project primary care survey 2017

^{Date created: June 2019}