NHS Stafford & Surrounds & NHS Cannock Chase CCG have been running a pilot over the past 14 months in primary care testing for faecal calprotectin. This was following recommendations from the NICE Diagnostics Guidance 11 (DG11): “Faecal calprotectin diagnostic tests for inflammatory diseases of the bowel”.
Recommendation 1.1 in the guidance states: Faecal calprotectin testing is recommended as an option to support clinicians with the differential diagnosis of inflammatory bowel disease (IBD) or irritable bowel syndrome (IBS) in adults with recent onset lower gastrointestinal symptoms for whom specialist assessment is being considered, if:
cancer is not suspected, having considered the risk factors (for example, age) described in Referral guidelines for suspected cancer (NICE clinical guideline 27), and
appropriate quality assurance processes and locally agreed care pathways are in place for the testing.
This example sets out a partnership approach with Ferring Pharmaceuticals, the local GP federation 'GP First' and the CCGs. GPs are now able to test a patient’s faecal sample in the practice to support a diagnosis of Inflammatory Bowel Disease (IBD) or Irritable Bowel Syndrome (IBS) if cancer is not suspected and where there is clinical uncertainty over the diagnosis.
Aims and objectives
The main objectives of implementing point of care testing in primary care are:
• To improve the patient experience for those with IBS and to reduce the number of patients undergoing invasive procedures within secondary care
• To reduce outpatient referrals into secondary care (32%)
• To increase the numbers accessing rapid diagnosis for IBS/IBD
• To improve pathways for the management of IBS
• To provide a structured programme to aid decision making in primary care
Reasons for implementing your project
Before introducing the testing in primary care, patients with an uncertain diagnosis of IBS/IBD would be referred into secondary care to see a gastroenterologist. This may have involved an initial consultation, a colonoscopy procedure and a follow up appointment to discuss results several weeks later.
The CCG had access to the total number of consultations and procedures taking place to act as a baseline, but this would have been total numbers, and it was not possible to identify just those attending with IBS symptoms from the data available at the time.
The local gastroenterologist supported the evidence that 32% of the patients that he saw ended up with a diagnosis of IBS and could have been managed in primary care without the need to go to hospital. Cannock Chase CCG has a population size of 132,000 and 26 member GP practices and Stafford & Surrounds CCG has a population of 146,000 and 14 member GP practices.
How did you implement the project
The CCG took several steps to implement the test in primary care, the key success factors are outlined below:
• Local GP engagement was key to the success and was secured in several ways. A full business case for the implementation was taken to the Membership Board, which has a representative from each practice and was agreed unanimously. This was then followed up by a Protected Learning Time (PLT) delivered by local Gastroenterologist Consultant to explain the benefits of the test to a wider group of GPs.
• The CCG worked with the local GP federation, GP First, to manage the logistics of the accounts and ensuring tests got to each of the 40 GP practices across the 2 CCGs.
• Ferring Pharmaceuticals supported the roll out of the project by providing training to practices and printing out waste disposal information. A clinical pathway was developed with the local Gastroenterologist and the CCG Clinical Leads to outline the circumstances that the test should be carried out. This was supported by a pathway on how to manage IBS in primary care and also delivered at the GP PLT education events.
The costs incurred by the CCG were the cost of the tests and distribution, £15 each paid to the GP Federation for a bulk order upfront and then an additional £15 enhanced service paid directly to the GP practice once the test had been undertaken.
Each GP practice has to send the CCG, on a monthly basis, a monitoring form which lists the number of tests carried out that month, the batch number of the test, the date it was carried out, the result and whether or not a referral to secondary care was required, as a result of the test being carried out.
The results are recorded on a master file for all practices to log the total number of tests that have been carried out and the number which were negative and the GP has confirmed that a referral was not required to secondary care.
Over the last 13 months period (July 14 – Aug 15) there have been a total of 833 tests carried out across the 2 CCGs and 467 of those were reported as negative and the GP has confirmed the patient was not referred to secondary care, a saving of 56%. This is higher than the anticipated saving of 32%.
The cost savings have been calculated on the basis that the CCG has saved 467 first outpatient attendances, 467 colonoscopy procedures and 467 follow up appointments. Once the investment cost of the tests have been deducted this has a financial saving associated at approx. £280,000.
There has not been a like for like deduction in the activity going through the contracts. This may be due to the fact that the age to screen for bowel cancer increased at a similar time that this project went live and there may have seen an increase in procedures for a separate cohort of patients presenting with other symptoms not relating to IBS. Due to the data the CCG has access to it is not possible to evidence the reasons for this.
Key learning points
The following points have been noted as key learning points of the project:
• The mobilisation phase was underestimated. The CCG’s original approach was to get each practice to set up an individual account with the pharmaceutical company and order the tests directly. Due to practice capacity this did not happen in the timescales we anticipated. A new approach was agreed whereby the GP federation would order the tests on behalf of all the practices and arrange for delivery of the tests to each practice. The training needs for each practice around how to use the test and dispose of the sample afterwards were only identified once the pilot had started and delayed a speedy uptake.
• There is still some further education needs to clarify exactly when the test should be carried out, based on some of the results coming through on the reports. For example some GPs are still referring patients when there is a negative outcome and vice versa. This is being addressed on a case by case basis.
• The CCG needs to have realistic expectations of the impact on the acute contracts – awareness of other influencing factors e.g. Increase of bowel screening age and anticipated growth.
• Further analysis is taking place to look at the diagnosis of those who were referred to secondary care – an audit is currently in progress.
The submission is supported by Ferring Pharmaceuticals Ltd. To date funding has only been received by the CCG to remunerate clinical engagement time.