How we can improve care for 240,000 with Inflammatory bowel disease
Almost a quarter of a million people in the UK suffer from inflammatory bowel disease. Over the year, AbbVie held a series of roundtables across the country aimed at identifying new ways to reduce service variation and improve patient care.
Inflammatory bowel disease (IBD) is a significant issue in modern British healthcare. Around one in 250 people – about 240,000 in total – live with one of two main conditions in the UK, both of which tend to appear at a relatively young age, leading to lifelong difficulties with health and an increasing financial challenge for the NHS
One is ulcerative colitis, an inflammatory condition of the large bowel. There is a 15-20% chance the large bowel will be removed through surgery. Crohn’s disease is slightly different, in that it can involve any part of the gastro-intestinal tract. Around 50-60% of patients require surgery from diagnosis. For appropriate patients, biologic medicines can bring benefit in managing the condition but in all instances, as with other long term conditions, designing a service that works for the individual, allows access to specialist care at the right time all the while operating within a sustainable service is an ongoing dilemma.
AbbVie recently held a series of roundtables to see how service redesign and the emphasis on greater self-management of IBD aligns with the objectives of NHS England to shift care closer to home and, moreover, how sharing best practice might support the NHS RightCare objectives of reducing unwarranted variation.
What resulted were a series of lively panel discussions that identified a number of simple and practical interventions that could provide cost savings, reduce pressures on NHS capacity and provide a more patient centred service. Common measures ranged from a focus on remote monitoring of stable patients outside of the hospital setting and addressing high levels of referrals, to better management of medicines usage and enhancing nurse-led care alongside improved patient education.
Starting within the terracotta façade walls of a Grade II-listed town hall in East Sussex, our first expert panel discusses the problems of a stretched NHS that is looking to bridge a £30bn funding gap over the next five years, mainly through efficiency savings.
The presenting consultant gastroenterologist tells the panel that in his area of Kent & Medway, IBD readmissions were higher than the rest of the country despite having admissions of an about-average 180 in 100,000 people. In addition, there were concerns that the referral criteria itself was not working appropriately, leading to higher rates of referral to more expensive specialist consultations than was necessary.
“The cost of those readmissions is going to be higher as well,” he adds. “Potentially we’re not doing the right things for our patients because they keep coming back into hospital.”
The consultant says data crunching showed the area was probably behind in starting early treatment with biologics and there weren’t enough IBD nurses or administrative support, which sucked up a “huge” amount of management time.
This helped prompt a change in West Kent, creating a new IBD patient pathway focused on increased self-management. This started with West Kent asking patients what care was like and where things were falling down.
This suggested there wasn’t enough contact with patients. A regional steering group was established, which came up with an options appraisal on what it could deliver on fastest, working out cost savings on basic drugs and where specialist nurses were needed. Work is now being carried out to standardise IBD care across the region.
Despite these successes it is pointed out that increased lifespans is one reason for an expected 53% increase of patients over the age of 60 with IBD in the coming years.
“No matter what we do here the costs are going to go up. The question is: can we do better with the funds that we’re given and can we contain the costs for the future?”
Pondering that question in the North-West of England, the next expert panel finds that there needs to be a flexible approach to care, enabling people to see doctors when they need to. This is more efficient than attending routine appointments irrespective of whether or not they are unwell, according to the consultant gastroenterologist from St Helens and Knowsley Teaching Hospitals NHS Trust.
“Budgets have been made to go further by more effectively monitoring medicine spend to ensure the most effective and appropriate use,” he adds.
Patients have a number of ways of being in contact with the IBD team, which reduces the chances of people resorting to turning up at hospital. Newly diagnosed patients attend an education clinic to help them manage their disease.
Those patients who are not assessed as needing to attend hospital in person are supported by a telephone clinic, which is another way of reducing the burden on hospital outpatient clinics.
“We have a very flexible system in operation which allows us to see them when they are needed and at the same time not lose contact with them.”
A more sophisticated approach to prescribing drugs, tailored to the needs of the individual patient and involving a multi-disciplinary team of IBD specialists, is also needed.
The new approach has not only saved money but enabled more time for patient care.
Doctors have been able to double the amount of time they spend during appointments from 15 to 30 minutes, cut the clinic waiting list from six to three months, and reduce unplanned admissions to hospital by 60% over the last two years.
It is not just North-west England where new ways of treating and managing patients are getting results.
The pressures of meeting tough targets in terms of budgetary savings are also driving innovative approaches to healthcare in King’s College London.
In south east London, six acute trusts and six CCGs have been involved in what has been a “huge effort” to change the way patients are managed.
The leading consultant here explains that the first step was to find out what patients wanted. A survey of around 500 patients revealed that 65% said they didn’t have enough time with their specialist nurse, with similar proportions who wanted access to psychologists and dieticians to help manage their disease.
One of the ways of supporting patients in managing their disease is a telephone hotline, which reduces the burden on hospital clinics – and has saved £4 for every £1 spent.
Testing for levels of calprotectin – a protein biomarker present in the faeces that signals intestinal inflammation – allows doctors to make faster diagnoses and fast track patients accordingly.
They also use therapeutic drug monitoring “a £60 test” that works to support “the right drug at the right time for the right patient.”
In the first year of doing this (2014-15) more than £1m was saved from the drugs budget in one hospital alone.
Another innovation has been a myIBD app, developed by clinicians and the Crohn’s and Colitis UK charity. This enables patients to not only keep track of their own medication, medical records and appointments, but share those details with the teams looking after them.
But underpinning all the new approaches is having IBD nurses in place to work with the doctors and support patients. Patient satisfaction has greatly increased, with 94.3% saying that the service was either good, very good or excellent, up from 82% previously.
“The one thing that’s transformed everything we’ve done is to have a team of specialist nurses,” concludes the presenting consultant. “For every pound we’ve spent on a nurse we’ve got four back.”
Funding and factual comment provided by AbbVie