This Gastroenterology Blog will keep track of all the activity undertaken by the Gastroenterology Sub Group, noting and reporting insights along the way, and will be a shared point of contact for anyone who wished to keep up to date on the groups progress or contribute to the ongoing work. If you have any enquires about the project or any of the blog posts, please go to the Scottish Access Collaborative contact page and email us direct.
On Wednesday the 25th of July, the Scottish Access Collaborative team met Consultant Gastroenterologist John Thomson and Operational Manager Vanessa Sandison at Aberdeen Royal Infirmary. This first event aimed at identifying the most common Gastroenterology outpatient symptoms and to start to map out the current pathways for these symptoms.
The meeting, supported by the Digital Health and Care Institute (DHI) design team, was the first of a series of design led workshops aimed at mapping and understanding the current state of clinical pathways for Gastroenterology. A prioritised list of key challenge areas and corresponding actions which help to improve bring down patient waiting times, and contribute to the key principles of the Scottish Access Collaborative can be identified.
Before defining the key challenges within the current gastroenterology services, it was vital to understand the current state. In order to break down the system into manageable elements, individual symptoms were chosen and profiled. This approach, once an agreed set of symptom profiles had been established, enables the pathways to be visualised based on these individual symptom profiles and their journey through services, making the task of mapping the current state more practicable.
The first action, was to discuss and define the most common Gastroenterology symptom profiles. A list of symptoms was formed based on the conversation with our two experts and their insights based on their experience. This resulted in a list of five symptoms, defined by their volume of presentation, as well as the reasons ‘why’ each symptom would be of interest to The Collaborative. This led to the following symptom profiles:
Change of bowel habit split into either diarrhoea or constipation, chosen because it has a large volume of presentations with more than 50 % of Gastroenterology presentations in secondary care. It is an anxiety inducing symptom that impacts on patient wellbeing, if blood is detected in diarrhoea it usually causes a significant alarm with patients, due to the possibility of cancer. There is variation in the journey for this symptom, resulting in a lack of consistency of the pathway route from GP referral.
Reflux/ dyspepsia (Heart burn indigestion) this symptom was chosen because it has a medium volume of presentation (approximately 10%), and it has a possibility of cancer so it requires urgent investigation. In the majority of cases (not cancer) the symptom is influenced by lifestyle and the patient’s weight is a factor, therefore there are treatment options for the patient that can be managed in primary care. For many patients, the care they need to receive is reassurance that they are not seriously ill, rather than any clinical action.
Abdominal pain (flank pain) was chosen due to the relatively high number of repeat GP appointments for reassuring the patient. Also, the symptom has a medium volume of initial presentation at approximately 15 %.
Non-specific weight loss is a symptom currently counting for approximately 10% of presentation, but it is increasing. In itself it is not a big issue but combined with other symptoms it can be critical. A big issue is a lack of knowledge of the options and pathways that are available in primary care, this leading to unnecessary hospital appointments.
(Incidental) Abnormal liver function test from GP is when a patient is referred to secondary care due to an abnormal liver function test, normally carried out at the GP surgery. This may be caused by the patient being overweight or drinking too much. The symptom represents a medium to large volume of presentations and so is a relatively significant number of cases. It was discussed that there is currently a discussion between primary and secondary and opportunities for more to be done in primary care.
After the symptoms had been defined, we collectively sketched an initial draft of the current state pathway for the Change of Bowel Habit symptom, as this was the largest volume of presentations and had significant potential for improvement. The aim of ‘mapping’ in this way was to develop an understanding of the current service blueprint, and focus in on a typical patient journey. It was agreed that the pathway starts with the patient going into a GP surgery for consultation, after examination the patient would be referred into secondary care where the referral is vetted and directed to the correct pathway. The patient would come into hospital and would undergo testing (endoscopy) at the Gastroenterology clinic. Once tests have been reported the patient would have a return appointment with the consultant.
In order to develop this initial understanding of gastroenterology services, capture a diverse picture of the current pathways including national differences, and to add more detail to the ‘map’, the wider gastroenterology sub group will be asked to contribute and share their thoughts on this mapping of change in bowel habit symptom, as well as, the remaining symptoms defined at a workshop scheduled for the 4th of September.
Furthermore, the group will highlight and current opportunities where services could see some positive change, and will be working on some suggestions for such improvements.
Gastroenterology Workshop Two: defining opportunities
On Tuesday 4th September, the Digital Health and Care Institute (DHI) design team, along with partners from the Scottish Access Collaborative, met with the whole Gastroenterology Sub Group for the first time to look carefully at the current state for Gastroenterology services in Scotland. Following an initial scoping workshop, this second workshop aimed to: collaboratively define some of the most significant symptoms this specialty deal with, focusing on the motivation for choosing each symptom and creating a basic ‘symptom profile’ to work on; map the current service blueprint typical for each symptom as it moves through the service, including the people, places and technologies involved; map the experiences from different perspectives of current services, from a broad range of relevant stakeholders; and finally, find some opportunities for innovation in the current services and locate them on our maps.
A Multi-Perspective Approach
Key to the work of the Access Collaborative is viewing current NHS services through the lens of multiple stakeholders, ensuring that opportunities are defined with a whole system perspective in mind. Therefore, the Gastroenterology Sub Group includes patients, GP, nurses, dieticians, managers, consultants, and surgeons, all with the aim of sharing the knowledge and experiences to ultimately improve services for everyone.
In the scoping workshop, some key Gastroenterology symptoms were identified as areas for focus. The first task in this second workshop was to feedback the scoping work to the group, ‘sense check’ the symptoms with the whole group, and then add details to each profile. By the end of this first task the group had defined five key symptoms:
Reflux and Dyspepsia
First the group talked about reflux and dyspepsia. Dyspepsia (indigestion) is a common problem of impaired digestion. Reflux, also known as Acid Reflux, is a condition where contents of the stomach come back up into the oesophagus. This symptom is problematic because it has a high volume of referrals and, critically, the current guidelines for the two symptoms result in a lot of referrals that often lead to no diagnosis after diagnostic testing, typically an endoscopy. Meaning many patients make unnecessary journeys to hospital for a fairly invasive test.
Incidental Abnormal Liver Function (from GP test)
The next symptom discussed was abnormal liver function, flagged by a liver function test by a GP. Abnormal liver function refers to abnormal liver enzyme test results, which can be a marker for other conditions, but often it is something that can be managed by the patient through lifestyle and diet changes. Abnormal results from Liver Function Tests (LFTs) are very common in primary care, and they are often found co-incidentally in patients who are not showing any symptoms. This symptom was chosen because there are a significant number of presentations in primary care who return abnormal LFTs, but few are referred to secondary. Yet, new guidelines will mean that more patients will present to secondary. Liver function is a complicated case, and liver function related issues can result in long periods of investigation with no added value to the patients.
Chronic abdominal Pain
Chronic Abdominal Pain is a broad term that deals with any long-term unexplained pain in the abdominal area, where there is no change in bowel habits of the patients. There is a medium volume of these cases referred to secondary, so it represents a significant number of patients who are dealt with. Referrals for this symptom can be variable. There are a large number of patients who are referred more than once after testing which produced a negative result. This symptom pathway can be variable depending on the region.
Unintentional Weight Loss (non-specific)
This symptom refers to patients who have started to show signs of clinical significant weight loss without intent, i.e. a significant change to their diet or lifestyle. It is a small to medium volume of presentations, however it poses a very difficult decision in primary with various pathway options. It is not always a gastroenterology issue, but knowing what is the appropriate referral is problematic.
Change of Bowel Habit
Finally change of bowel habit was discussed, primarily because lots of ‘things’ fall into this definition, it can mean either diarrhoea, constipation, change in frequency, etc. It represents a large volume of presentations and crucially a lot of presentations are deemed to be inappropriate for gastroenterology consultation as there is little that can be done that could not be managed by the patient, community, or primary care.
Current State Mapping
Once the symptoms had been discussed the group prioritized the five symptoms down to four, and began to look at the current patient journeys and service blue prints for each, highlighting opportunities for innovation. The four symptoms for focus were:
- Unintentional Weight Loss
- Change of Bowel Habit
- Chronic Abdominal Pain
For the remainder of the workshop the group broke away into four groups, each with one of the four symptoms to focus on, and mapped current pathways for their symptom, highlighting the people, places, and technologies involved. Plus, insights into the impact and experiences of each part of the pathway for the perspective of each of the stakeholders. The group uncovered lots of great insight into the current states of services and highlighted the potential areas for future innovations The key findings include:
For REFLUX the big opportunity is in the diagnostics. Our research indicates that the majority of cases are referred, one way or another, for an endoscopy and that the overwhelming majority of those tests find nothing, putting strain on the demand for this test. It doesn’t confirm reflux, and patients end up back on medication they were on before the scope. The patient ends up in a loop of treatment, test, treatment. The question is how can this cycle be broken?
For CHRONIC ABDOMINAL PAIN, many patients would be better served with a dietetic service than
a hospital visits to see a consultant. Currently they can end up in a ‘revolving door’ situation where they get lots of inconclusive tests, putting demands on them and the service. The question is how to support and properly resource primary and community services to ‘screen’ and triage those patients who do not need a hospital visit?
The symptom CHANGE IN BOWEL HABITS is a problematic symptom, It is a difficult symptom for primary care to deal with in terms of appropriate referral, therefore patients presenting in Gastroenterology clinics are often not Gastroenterology cases. Efficient, appropriate, and timely treatment this symptom relies on a good patient profile, but currently there is not the resource to do this adequately. So, the questions are; is the term right, can it better nuanced? How can the conversation between patient and clinical staff be improved? Could there be an engagement with patients before their GP appointment to help frame the GP questions and history taking? What additional role could Dieticians play in patient engagement and vetting?
Finally, for UNINTENTIONAL WEIGHT LOSS, patients falling into a diagnostic loop between specialties without any resolution is a big opportunity for improvement. The cause of this symptom is ambiguous, and can be the result of dentistry issues, psychological factors, infection, and more, so patients can be passed around before a cause is resolved and treated. The question is how more can be done, perhaps pre-primary care, to support appropriate patients to try self-management strategies and be supported to ‘navigate’ the various care options available to them.
The next steps will be for the DHI design team to develop the insights from this phase of the Gastroenterology work into some key challenges, ready for the group to come back together early in October in a third workshop, and collaboratively develop some ideas to address them.