Many people are waiting too long for a diagnosis of Inflammatory Bowel Disease (IBD). This is distressing for those who are waiting, with often painful and debilitating symptoms and no effective treatment. It’s also costly for the NHS as delayed diagnosis results in higher likelihood of surgery, more expensive treatments and a poorer prognosis. It can be difficult for GPs to identify potential IBD as the symptoms overlap with other conditions, such as irritable bowel syndrome, and can be atypical, especially in children. Clear pathways and protocols, including the use of faecal biomarkers, can speed up diagnosis and lead to better patient outcomes.

Who's doing it well?

The Yorkshire & Humber Academic Health Science Network worked with York Teaching Hospital NHS Foundation Trust to develop and implement a pathway for faecal calprotectin to improve diagnosis. This included providing templates and leaflets for GPs and patients to help them use and understand the process.

The idea

Yorkshire & Humber AHSN and York Teaching Hospital were involved in a task and finish group coordinated by the office of the NHSE Chief Scientific Officer to provide recommendations on the spread of faecal calprotectin testing in primary care and identify a pathway for widespread use. The resulting paper and algorithm were reviewed and endorsed by the National Institute for Health and Care Excellence (NICE) and Crohn’s & Colitis UK, who also supported the widespread communication and dissemination of this pathway. The endorsement by Crohn’s & Colitis UK led to the pathway being included in the Royal College of General Practitioners’ (RCGP) IBD toolkit. It is also on the NICE Shared Learning Database.

The first stage of spread was locally within Yorkshire & Humber. To support spread and adoption across Yorkshire & Humber the project team provided programme management and clinical support, templates for SystmOne and Emis, and GP and patient leaflets which could be locally adapted. The success of the project in Yorkshire, and the national promotion of the pathway through NHS England, NICE and the RCGP led to the project becoming an AHSN Network Collaborative programme. Over the two-year AHSN programme, the pathway has spread into 71 CCGs across England. There is a page on NHS Futures for the leads in the different AHSNs to collaborate, ask questions, acquire resources, and share successes and challenges.

When recommendations for faecal immunochemical testing (FIT) were released, the learning from implementing the faecal calprotectin pathway was used to develop a FIT pathway. The symptoms of patients who would be eligible for a FIT test (low risk colorectal cancer) are similar to those who would need a faecal calprotectin test, so a lower GI pathway was designed to incorporate both faecal calprotectin and FIT testing. This pathway was picked up and replicated by others such as in Harrogate, and by South Yorkshire & Bassetlaw ICS/Cancer Alliance.

Results

York Health Economics Consortium (YHEC) were commissioned to perform a health economic evaluation after implementation across York, Scarborough, Bridlington and Whitby.

• It found that per 1000 patients tested:
• there were financial benefits of up to £160K saved to the health economy
• there was a reduction of up to 267 unnecessary outpatient appointments
• there was a reduction of up to 289 unnecessary colonoscopies
• the pathway’s sensitivity was 94% and specificity was 92%
• it was a dominant pathway compared to all but one comparator pathways
• benefits would start to be realised as soon as 1 GP practice started using the pathway.

After the pathway had been live in York for a year, York Teaching Hospital performed an audit of endoscopy outcomes. It showed a saving of £42,000 in endoscopy services per 1,000 patients faecal calprotectin-tested, a reduction in waiting times for patients, and a reduction in the number of patients needed to diagnose IBD from 6.8 to 3.8 patients. The number of referrals from primary care after a patient had undertaken an faecal calprotectin test reduced from 24% to 13%- this enables the time and capacity of endoscopy services to be better utilised for those patients who need it most.

In addition to the health economic analysis, YHEC looked at Health Related Quality of Life (HRQoL) calculations. When the HRQoL were added to the financial benefits of the pathway and its comparators, the pathway demonstrated a Quality Adjusted Life Years (QALY) benefit compared to all comparator pathways.

The project team found that implementation was more challenging where stakeholders from all aspects of the pathway (primary care, secondary care and labs) were not in the same room from the beginning and questions and issues needed to be raised several times for all stakeholders to understand and work through problems. The team also found pushback on the type of test used within the labs which was addressed within the pathway to ensure patients who needed a referral could still receive this.

^{Date created: April 2021}