Quality statement 1: Specialist assessment

Quality statement

People with suspected inflammatory bowel disease have a specialist assessment within 4 weeks of referral.

Rationale

A confirmed diagnosis of inflammatory bowel disease is always made in an age‑appropriate specialist setting using a combination of haematological, endoscopic, histological and imaging‑based investigations. A delay in assessment and diagnosis can be associated with adverse consequences, such as clinical complications and a negative effect on the person's quality of life. Some people with suspected inflammatory bowel disease who have severe symptoms will need an urgent specialist assessment, the urgency of which will depend on clinical need and might include an emergency admission, but no one should wait more than 4 weeks from referral for a specialist assessment.

Quality measures

Structure

Evidence of local referral pathways to ensure that people with suspected inflammatory bowel disease have a specialist assessment within 4 weeks of referral.

Data source: Local data collection. Data on referral pathways for urgent referrals are available in the National audit of inflammatory bowel disease (IBD) service provision, question OC1.2, and the National audit of paediatric inflammatory bowel disease (IBD) service provision, question OC2.1.

Process

Proportion of people with suspected inflammatory bowel disease who have a specialist assessment within 4 weeks of referral.

Numerator – the number in the denominator who have a specialist assessment within 4 weeks of referral.

Denominator – the number of people with suspected inflammatory bowel disease who are referred for specialist assessment.

Data source: Local data collection. Data on the time it takes for urgent referrals to be seen are available in the National audit of inflammatory bowel disease (IBD) service provision, question OC1.3, and the National audit of paediatric inflammatory bowel disease (IBD) service provision, questions OC2.4 and 2.6.

Outcome

Patient experience of the referral process.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (district general hospitals) ensure that local referral pathways are in place so that people with suspected inflammatory bowel disease are referred quickly and efficiently, and have a specialist assessment within 4 weeks of referral.

Healthcare professionals ensure that they follow agreed local referral pathways so that people with suspected inflammatory bowel disease are referred quickly and efficiently, and have a specialist assessment within 4 weeks of referral.

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that make use of agreed local referral pathways so that people with suspected inflammatory bowel disease are referred quickly and efficiently, and have a specialist assessment within 4 weeks of referral. This can be achieved through enhanced monitoring of contracts and establishing regular and timely auditing procedures.

What the quality statement means for patients, service users and carers

People with suspected inflammatory bowel disease are seen by a specialist in hospital for an assessment within 4 weeks of being referred by their GP. This means that a diagnosis can be made without delay and treatment options can be discussed. The specialist assessment might involve having blood tests or endoscopy (using a camera to provide images of the inside of the body). Inflammatory bowel disease includes Crohn's disease and ulcerative colitis. Sometimes it is not possible to tell whether a person has Crohn's disease or ulcerative colitis, and they may be described as having 'inflammatory bowel disease unclassified' (IBDU).

Source guidance

Definitions of terms used in this quality statement

Suspected inflammatory bowel disease

People with any of the following lower gastrointestinal symptoms that have been present for at least 6 weeks should be suspected of having inflammatory bowel disease:

  • abdominal pain or discomfort

  • bloating

  • change in bowel habit (such as diarrhoea with or without rectal bleeding).

Faecal biomarkers, such as faecal calprotectin, alongside clinical assessment may be useful in primary care to distinguish between suspected inflammatory bowel disease and non‑inflammatory bowel disease, such as irritable bowel syndrome. [Adapted from Faecal calprotectin diagnostic tests for inflammatory diseases of the bowel NICE diagnostics guidance 11, section 3.1, and IBD Standards, standard A4]. The Quality Standard Advisory Committee noted that, in some people with severe symptoms, inflammatory bowel disease might be suspected before the symptoms have been present for 6 weeks, and these people need earlier referral (before 6 weeks).

Specialist assessment

People with suspected inflammatory bowel disease should be referred for specialist assessment using local referral pathways by a GP directly to a defined specialist (consultant gastroenterologist or consultant paediatric gastroenterologist) or to an age‑appropriate inflammatory bowel disease service. Specialist assessment enables consideration of a possible diagnosis of inflammatory bowel disease using a range of investigations. These include clinical evaluation and a combination of biochemical, endoscopic, radiological and histological investigations to confirm a diagnosis. [Expert opinion and British Society of Gastroenterology guidelines, section 3.3]

Within 4 weeks of referral

The timeframe of 4 weeks is based on expert consensus and is intended to be a safety net to ensure that no one waits longer than 4 weeks for specialist assessment. However, it is recognised that some people with suspected inflammatory bowel disease who have severe symptoms will need an urgent specialist assessment. In such cases 'within 4 weeks' is subject to clinical judgement and a considerably shorter timeframe may be necessary, for example within 2 weeks. Therefore an effective local referral pathway should ensure that people with suspected inflammatory bowel disease are seen within 4 weeks of referral, or more rapidly if clinically necessary. Services that already see patients earlier than 4 weeks from referral should maintain this speed of referral and assessment. [Expert opinion and IBD Standards, standard A4]

Equality and diversity considerations

The symptoms of inflammatory bowel disease may have a different impact on people of different gender, sexuality, culture and age. Referral processes and assessments need to be sensitive to individual anxieties and take into account any additional needs, such as the availability of doctors of the same sex, and any language barriers.