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Project Background

Routine gastroenterology waiting list: 144 weeks (784 patients)

Urgent gastroenterology waiting list: 53 weeks (328 patients)

39% increase in referrals to secondary care gastro service

20% of patients referred to secondary care gastro are diagnosed with functional gut issues

Reduced gastro consultant staffing: 2 WTE, 1 part time;

Ideal staffing is 6 WTE per population of 250,000
Inability to recruit over past 4 years

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Aims

Create ACP Dietitian Led Gastroenterology Clinic

Band 8A Dietitian; 0.6 WTE Band 3

Patients referred to secondary care gastroenterology services will be triaged by gastro consultants via Referral Management System;

those identified as likely functional gut issues will be referred directly to dietitian for initial assessment, diagnostics and management

Reduce current 144 week waiting list of routine gastroenterology patients

Enable consultants to see urgent or more complex patients timely, reducing risk of admission and improving management plans for patient

Provide a more streamlined, safe and effective pathway for the patient

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Objectives

Engagement with stakeholders – patients, GPs, consultants Clinical governance – develop pathways, agreed scope of practice for dietitian Clinical – set up new clinical service, develop competencies, weekly supervision with gastroenterology consultant Data collection – qualitative and quantitative

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Project Approach

Established 4-5 new patient clinics per month (20 patients per month)

Established 2 follow up clinics per week (48 appointments per month)

Gastroenterology consultants triage referrals and identify those appropriate for ACP Dietitian Clinic as part of Referral Management System (RMS)

Weekly 1 hour supervision with gastroenterology consultant to review cases and organize investigations

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Project Outcomes

Clinical Activity 259 referred by Gastroenterology Referral Management System (RMS) team 225 patients seen in clinic 66 patients contacted from 3 year waiting list 27 removed from waiting list as either non-responders to invite to attend or declined appointment as symptoms improved since initial referral = 318 people in total, not added or taken off gastroenterology consultant waiting list in 12 months Referral time Reduced from 3 years to 3-4 months for low-risk gastroenterology patients Re-referrals back to gastro consultants 3 at dietitian request 1 at patient request 3 at consultant request

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Project Outcomes

86 (38%) of patients managed fully without consultant input clinic before discharge 139 (62%) of patients required some form of input from gastro consultant to arrange further investigations. Many of these were simply a signature to request investigation rather than detailed review

Investigations	Number
Colonoscopy	40
Sigmoidoscopy	12
Endoscopy	35
CT Scan	20
MRI	11
SehCat	13
US abdo/ pelvis/ TAV	35
Total	166 investigations for 139 patients

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Project Outcomes

Diagnosis Most new diagnoses were managed completely by the dietitian with a combination of commencing on medication, diet and lifestyle. Exception: Cancer, colitis, polyps, gynae

Diagnosis	Number
Colonic cancer	1
Bile acid diarrhoea	7
Pancreatic enzyme insufficiency	8
Small intestinal bacterial overgrowth	8
H.pylori	3
Rectal/colonic polyps	6
Gastritis/oesophagitis/duodenitis	32
Hiatus hernia	5
Diverticular disease	18
Colitis	2
Gynae related	6 (onward referral)
Functional gut	129

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Project Outcomes

Consultant time 225 new appt consultant slots released (30mins each, 112hrs consultant time released) 225 follow up appt slots released (20 mins each, 75hrs consultant time released) Plus, associated admin – letters, reviewing, actioning results est. 30mins per patient =112hrs = 500 appointment slots released a year, 299 hours consultant time released (39 days) Over 12 months, 32 supervision sessions between dietitian and consultant for 139 patients (either to arrange investigations or review case) On average 35 - 45 mins of consultant time = 19 - 24hrs of consultant time per annum Estimated 3 - 6 full days a year of consultant time to support dietitian led gastroenterology clinic (1 hour per week provision but not always used due to staff shortages)

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Project Outcomes

Capacity 1400 new appointments available in gastro consultant clinics per annum / 250 new slots in dietitian led clinic = 18% increase in gastro consultant clinic capacity a year if low risk patients are triaged to Dietitian led clinic 2064 follow up appointments available in gastro consultant clinics 250 follow ups in dietitian led clinic = 11% increase in gastroenterology consultant capacity a year = Total 14% increase in gastro clinic capacity a year 275hrs or 1250% increase in gastroenterology consultant hours (24hrs vs 299hrs) to see more urgent, complex patients

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Project Outcomes

Cost Effectiveness 225 new appointments @ £320 per appt = £72,000 225 f/u appointments @160 per appt = £36,000 = £108,000 minimum cost saving in consultant time

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Did it Work?

Has become embedded within gastroenterology pathways as an alternative route for patients

Established good communications and shared care with gastroenterology consultants, GPs and patients

Evidenced that patients can be assessed, investigated, diagnosed and managed by ACP Dietitian

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Stakeholder Feedback

Patient Feedback

How did you find the service you received overall?

Excellent 90%
Very good 10%

Did you feel reassured that your concerns had:

Been listened to Yes absolutely
Been understood Yes definitely

Did you receive the care you expected in terms of:

Addressing your symptoms Yes definitely 100%
Investigating your symptoms Very effective 100%

Did you feel the right care compared to seeing a gastroenterology consultant

All said “yes definitely” – “to me, she specialises in this and by working in this way it saved me from having to go to a consultant

And finally, a quote from one patient “ I have to say that this is a 5 star team. They work quietly in the background without any fuss and bother and just worked hard – they deserve an award for this work

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Stakeholder Feedback

Gastroenterology Consultant Feedback

Dr Mathialahan

The Dietitian First Clinic has been very helpful in reducing the waiting time for this group of patients and therefore reduced the time experiencing impaired quality of life and poorly controlled/undiagnosed symptom.

Dr B. Ahmad:

Data presented including patient feedback both strongly suggest that we should continue this service and even try to recruit more to this service. It has also helped in improving staff skills and have given department an extra reliable support for outpatient work.

Dr P George:

Dietician led services off load the overstretched gastroenterology service with a waiting time of more than three years. These patients do not need consultant input and are best managed by dieticians. We can triage the right set of patients to this essential service. It is the most cost effective and efficient way to run the clinical service in Wrexham. Failure to do so will result in complete collapse of GI service at Wrexham.

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What Next?

Aiming to acquire permanent funding for this post

Identified other areas of gastroenterology where pathways can be re-evaluated and improved with joint work between the gastro consultants, nurses and dietitian

With support of Bevan Commission, look to promote adopt and spread of this role/service

Publish work in journals to promote the work and feasibility of adopting and spreading such a service elsewhere

Create ACP gastroenterology dietitian network to standardize competencies and job roles

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Conclusion

Utilizing skill mix of broader members of a team can provide safe, clinically effective and high-quality levels of care for identified patient groups

Reduce patient waiting times
Reduce routine waiting list
Provide accurate and prompt assessment, diagnosis and treatment for patients
Increase consultant capacity to see more urgent and complex patients

Shared vision and clear communication are key to improving services