Non-face-to-face delivery of an inflammatory bowel disease service

Inflammatory bowel disease (IBD) is a lifelong condition with patients experiencing flare-ups that vary in frequency and severity.

Management of IBD patients has historically consisted of routine periodic clinic reviews, which arguably have limited benefit to clinical outcomes where patients are stable. This utilises capacity and increases waiting list times. This also limits the resource available to provide early intervention to patients whose condition is deteriorating, resulting in poorer patient outcomes and preventable hospital admissions.

Situation

The East Surrey Hospital (ESH) IBD service looks after approximately 4,000 patients.

Prior to reform, the service was run with 1.5 whole-time equivalent (WTE) IBD consultants and 1 WTE IBD clinical nurse specialist. This was well below the national minimum as recommended by British Society of Gastroenterology (BSG) guidance.

Stretched staff resources caused long waiting times for outpatient care, resulting in adverse patient outcomes such as emergency admissions for flare-ups.

The use of routine appointments resulted in stable patients being reviewed without the true necessity of a face-to-face consultant appointment. This added to the waiting list with little benefit to patient outcomes.

Aspiration

The initial aim of lead consultant gastroenterologist, Dr Ansari, was to restructure the service to tackle these long waiting times. This needed to be done in a way that maximised the use of resources in order to improve the quality of care which could be delivered to patients.

It became clear very quickly that success was heavily reliant on making the service more remotely accessible to stable patients, while providing them with the necessary information and tools to play a part in self-management of their IBD.

Solution and impact

In 2014, the service was radically redesigned to provide open access through telephone and email support.

This led to the introduction of a patient management portal called Patients Know Best (PKB), which allows patients to record their symptoms and communicate with the IBD team remotely. It enables access to timely advice and clinical review, prompting escalation where necessary.

This enabled the beginning of a complete restructuring of the service, improving the use of hospital resources and improving patient outcomes.

The service enables the patient to become educated in monitoring their condition, helping them to identify deterioration and access professional advice.

Patients who are stable but have concerns can be reassured without the need for a face-to-face appointment. This has reduced waiting list times, releasing appointment slots which can be used for patients requiring a specialist review, additionally reducing emergency attendances.

Impact

The technology has supported a complete transformation of the service, which is now able to deliver excellent quality care, with fewer than the nationally recommended number of staff (based upon its size).

Patient access to specialist care at time of a flare-up has reduced from 6 weeks to 1 week.

The redesign of the service saves around 650 patient hospital attendances each year, including 80 inpatient admissions.

This translates to savings of £232,320 in 2015 (from hospital admissions alone) and to a carbon saving of at least 60 tonnes CO2e.

The hospital has also managed to optimise use of low dose Azathioprine with Allopurinol by monitoring and managing side effects through PKB. This has resulted in fewer patients requiring biological therapy, which translates to enormous cost savings. This would not have been possible on such a scale without an open channel of communication between patients and the clinical team.

By optimising both the quality and accessibility to care, less of the ESH IBD patient cohort began requiring operations. Operation rates in 2015 were 80% less when compared with operation rates in 2008. This equates to potential savings of approximately £1.5 million per year on operations alone.

Out of 35 patients surveyed, 68% said having remote access to care had a positive impact on their IBD, 77% said it helped them feel more confident in managing their own health, with 57% stating it had improved their quality of life.

Functionality

• PKB is a web-based patient management portal
• Patients are set up with an account to log into the website

Capabilities

• Patients can record their symptoms and communicate with the IBD team remotely. This accelerates access to timely advice and clinical review for flare-ups
• The service can remotely monitor the side effects of treatment with Azathioprine and Allopurinol at scale through PKB, enhancing treatment success and preventing patient progression to more expensive biologic agents, which often require administration in hospital
• Patients are given access to their personalised healthcare record including diagnosis, investigations and results, medication histories, allergies, and links to patient information resources
• Patients can also schedule an appointment through PKB, which allows the patient greater flexibility which has improved patient engagement with the service

Scope

PKB is a care portal intended to be used by the patient from home to monitor their own disease, educate them on their condition and self-management, and to connect them with their clinical team on-site.

Key learning points

Work was undertaken with local clinical commissioning groups (CCGs) to develop a block contract for £300,000 per year to fund the quantity of non-face-to-face (NFTF) activity and create additional staffing posts. Payment by results was not a viable funding model for this type of activity, as remuneration is £90 less for a NFTF appointment and would have created a £160,000 shortfall per year.

When first setting up the NFTF service, initial demand far exceeded the capacity of the service.

There was significant resistance to change initially, due to the potential for reduced Trust income, clinician fear of open-door access, and lack of a commissioning model. The initial investment required for IT solutions was also significant.

The digital solution was a response to patients’ needs and evolved in real time as their needs changed. In many ways, the PKB model, if allowed to be open access, is driven by the ‘consumer’ and will always end up as the best solution in an environment with so many variables and confounders for outcome analysis.

Key figures/quotes

“In many cases, we can avoid A&E visits and that’s good news for the patient - and for our hospital.”
Dr Azhar Ansari, consultant gastroenterologist, Surrey and Sussex Healthcare NHS Trust

“I use it as a quick way to contact the people I need to get in touch with at a much quicker timescale than it would take me if I were to use the other services. By early intervention, it allows me to prevent my condition from getting worse and then having to use the other emergency services.”
Liam, patient of ESH IBD service

Find out more

Read more about non-face-to-face delivery of the inflammatory bowel disease service (PDF, 198KB)

Read "Flare to Care" - a research study on IBD care

Read case study: "PKB - a lifeline for a bright student"

Read "A population-based model of care for people with IBD - patient-reported outcomes"

Key contact

Dr Azhar Ansari, consultant gastroenterologist, Surrey and Sussex Healthcare NHS Trust

azharansari@nhs.net

Supplier: Patients Know Best

communications@patientsknowbest.com