Wolverhampton Gastroenterology Clinical Assessment Service

Contents 1. Introduction 3 2. Intervention 4,5 3. Our Approach 6 4. Outcomes & Benefits 7-9 5. Lesson Learnt 10 6. Next Steps 11 7 Appendices CAS Proforma Specific Pathways Key Contact: Dr Brian McKaig Consultant Gastroenterologist and Deputy Medical Director brian.mckaig@nhs.net

1. Introduction Between 2012-2013, a 25% increase in new outpatient (OP) gastroenterology (GI) referrals was observed at Royal Wolverhampton NHS Trust in comparison to the preceding year. This increase in demand resulted in significant pressures, both financial and organisational, to meet national standards. In response to pressures to meet national Referral-to-treatment targets. Royal Wolverhampton HS Trust (RWT) and Wolverhampton CCG met in an attempt to identify a more efficient and cost effective way of managing OP services. This led to the development of the Clinical Assessment Service (CAS); whereby GI Consultants triage patients to the most appropriate pathway in a timely manner. The aim was to and empower GPs to manage more GI patients in the community. Previously GI referrals to RWT 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 challenge this model by allowing secondary care GI 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, reduce expenditure . Both RWT and the CCG were also keen to empower GPs to manage more GI conditions in the community. The service was run as a pilot prior to full implementation in order to assess clinical and financial feasibility.

2. Intervention (1/2) Process GPs send in a standard referral letter (no template is in place) and the proforma is completed by secondary care consultants who also request any necessary pre appointment investigations. Demographic details are prepopulated on the CAS proforma followed by a requirement to choose the indication for referral, required investigations after initial triage and the final CAS outcome. There are 4 possible outcomes Outcome 1 is to offer an OPD appointment either as a fast track, urgent or routine slot. Outcome 2 is to offer an appointment but also request some simple investigations to take place prior to OPD review that will aid further decisions. Outcome 3 is for those suitable for direct testing such as endoscopic or radiological investigations. Results are then reviewed by the consultants before deciding further outcome (discharge or OPD). Outcome 4 is when a referral is deemed to be inappropriate for Gastroenterology. The patient is referred back to the GP with an advice letter and suggestion for alternative treatment pathway. Wherever possible, standardised letters were developed to streamline the above process. The proforma is also linked to a database where information can be extracted and used for audit purposes Nominated GI Consultants were given allocated sessions to review and action referrals within an agreed timeframe of 3 weeks from the GP referral being received at RWT to the patient being aware of management plan. Investment Initial start up costs to cover 1PA of consultant time for 5 months and IT support (c. £3-4K to set up IT system and database done in house by IT team at Trust). Subsequently recognised need for full time CAS administrator which was funded through the directorate secretarial pool. Specific clinical pathways Pathways for the 5 most common referral indications were developed with primary care to ensure consistent and optimal patient triage. These pathways incorporated national guidelines and were intended to support GPs manage more GI conditions, as well as provide a standard for internal auditing. See appendix 2

2. Intervention – CAS Flow Chart (2)

3. Our Approach What we did How we did it Tested clinical care, patient safety & impact of proposed CAS on financial modelling Undertook a blinded, retrospective audit of 300 GI referrals prior to CAS to ensure clinical care and patient safety would not be compromised following the implementation of CAS, and also to inform financial modelling for CAS proposals. Created bespoke IT Provided IT department with financial and clinical support to develop a unique data platform and electronic CAS. See appendix 1 Agreement on financial arrangements Discussions Wolverhampton CCG, with additional agreement obtained from 18 other referring CCGs in the area to use the pathway Identified the number of consultant sessions required and timeframe for review and action of referrals Analysed the pilot study. Two sessions with the number of participating consultant minimised to 2 ensured consistency. Nominated GI consultants were given allocated sessions to review and action referrals with an agreed timeframe of 3 weeks from GP referral being received to the patient being aware of the management plan. Allowed time for the new system to bed in and be understood by GPs and patients Fast track cancer pathway remained unchanged and other referral methods kept open until new service became familiar. Information letters were distributed to familiarise patients and GPs with the service and a dedicated clerical staff was hired for CAS related admin work.

4. Outcomes & Benefits (1/3) A total of 14,245 GP referrals were made in this period. A total of 9,773 referrals were triaged via CAS. The rise in demand from December 2014 was secondary to the merger with Cannock Chase Hospital following the dissolution of Mid Staffordshire Hospital. The main indications for referral were dyspepsia, abdominal pain and diarrhoea.

4. Outcomes & Benefits (2/3) Overall, 32% of CAS triaged patients were managed without a face to face GI consultation in clinic. This corresponds to 3,136 less OP appointments at RWT over the 3 year period, equating to 448 new OP 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 (n = 9,773). This equates to saving 361 clinic sessions. Overall CAS outcomes CAS Outcomes A new OP appointment was offered to 60.1% (n=5873) either as a fast track, urgent or routine slot. A total of 23.8% (n=2326) had investigations arranged prior to their OP appointment A total of 5.5% (n=538) were discharged back to primary care with a letter of advice. Re-referral rate of patients not seen face to face was 0.5% No serious pathology was missed in the re-referred cohort of patients

4. Outcomes & Benefits (3/3) Performance Indicators Following the introduction of CAS, departmental 18 week target performance improved from 96.5% to 98.5% in 2014. 18 week target performance remained stable at 96.4% and 95.8% for the following two years, despite the merger with Cannock Chase (population of 140K). Waiting times dropped from 53.8 to 32.2 days in 2014. This increased to 47.2 in 2015 and 51.4 in 2016. This is still within the 12 week target Financial Using the number of patients not requiring an OP appointment, it is possible to calculate gross savings achieved. The formula used was [(Outpatient clinic tariff) – (CAS clinic tariff) X Number of OP appointments avoided]. Over a 3 year period, it is estimated that a total of £481,613 was saved. DNA and Re-referral Rates DNA rates dropped from 14% prior to implementation to 7% in 2015 and 8.52% in 2016. The total re-referral rate for patients not seen in a face to face GI clinic was low 0.5%. (Re-referral was defined as the acceptance of a second CAS referral for the same complaints within a 12 month window). No serious pathology was missed in the re-referred cohort of patients

5. Lessons Learnt It can be challenging to develop and implement a new service requiring agreement and collaboration from various stakeholders. The CAS model has provided improved performance target attainment and delivered a financial saving. Whilst there are administrative costs involved, it is clear that CAS offers value for money. CAS has also provided a platform through which providers can have clinical discussions with CCGs. Initially we underestimated the amount of administrative time / work required - the appointment of a full time administrator made the process much easier to manage. We also found that limiting the triage process to 2 or 3 consultants provided a more consistent approach and allowed for easier and more meaningful comparisons between these consultants. We now have 6 monthly review of triage outcomes and discuss differences (between ourselves and with the wider GI team) to ensure that we are being consistent and complying with any available guidance.

6. Next Steps Are there plans to improve upon what has been delivered Ongoing work with the CCG clinical leads to develop further pathways in accordance with national guidelines e.g. abnormal LFT guidelines Now incorporated faecal calprotectin into pathways for diarrhoea Is there a stepped approach and has this changed following evaluation from work to date We review outcomes on a 6 monthly basis to identify areas of variance Outcomes discussed with the entire GI team 6 monthly to ensure pathways are agreed Will this model be adapted for other areas The CAS model has been adapted and adopted by the renal directorate at RWT for triage of renal OP referrals Does more work need to be done to make this sustainable? No Can this work be adopted into the STP? Yes. We have discussed this with several other trusts (outside the STP) who are adapting to suit their internal IT systems and our early feedback is that this has been feasible.

Appendix 1

CAS abnormal LFT pathway Appendix 2 Abnormal LFTs Local process in development to allow BSG guidance to be followed with minimal patient contact where not required. (DTT – fibroscan; automated FIB4 scoring) Liver OP appt CAS abnormal LFT pathway

CAS CIBH pathway Discharge with advice Constipation predominant symptoms Check U&E, LFT, Ca, TSH, FBC Normal? OP routine at discretion of Cas cons if complex case Diarrhoea predominant symptoms Check U&E, LFT, Ca, TSH, CRP, Coeliac, FBC, B12, folate, ferritin, Faecal calprotectin OP appt Routine or Urgent Pending symptoms/results If referrals is due to previously investigated symptoms then option to discharge with advice CAS CIBH pathway