Drs Lisa Das (left) and Steve Fox discuss current and potential ways of improving care for gastrointestinal disorders and the need to consider the rising demand for service provision
- Although gastrointestinal conditions have a considerable impact on the economy and healthcare workload, they do not receive the necessary recognition
- Gastrointestinal cancers represent a significant proportion of total cancer prevalence and morbidity
- Endoscopic examination is the gold-standard test for patients with gastrointestinal problems and can be offered via a number of referral routes
- A one-off flexible sigmoidoscopy screening test is being introduced—this will be offered to all patients when they reach the age of 55 years
- Programmes such as the National Awareness and Early Diagnosis Initiative and the NHS Bowel Cancer Screening Programme will improve gastroenterology care, but will also place a huge demand on services
- Commissioners have an important role in applying the quality, innovation, productivity, and prevention agenda to gastroenterological care.
Gastroenterology is unique in its multifarious disease umbrella, ranging from benign disease (such as gastro-oesophageal reflux disease, peptic ulcer disease, and coeliac disease), functional gastrointestinal diseases (FGIDs; such as dyspepsia, irritable bowel syndrome, and globus), inflammatory bowel disease (IBD), liver and pancreatic diseases, alcohol-related gastrointestinal problems, obesity, and nutrition.
Gastrointestinal and liver disorders are common conditions, together accounting for nearly 14% of the total inpatient NHS budget.1 It is estimated that gastrointestinal symptoms result in:1,2
- 10% of GP consultations (representing a cost of £136 million in the UK in 2001)
- 10% of hospital-specialist workload
- 14% of the drug budget.
The non-NHS economic impact of gastrointestinal disease is even costlier for the British economy:
- 147,400 person-years were lost due to people aged 20-65 years dying because of gastrointestinal diseases (based on data from 1980 to 1994)3,4
- the cost of early death from gastrointestinal conditions was estimated to be £3.23 billion in 20043
- 46,680 person-years of productivity were lost due to long-term sickness absence from work (based on data from 1980 to 1994),3 with an estimated cost of £1.05 billion in 20043
- in the British Society of Gastroenterology’s 2006 strategy on care of patients with gastrointestinal disorders, it was reported that:3
- one-fifth of all short-term sickness was due to gastrointestinal disease, with an estimated annual cost of £2.9 billion
- the total non-NHS cost to the British economy of gastrointestinal disease was £7.2 billion annually.
The malignant spectrum of gastrointestinal disease includes cancers that are very prevalent both worldwide and in the UK:
- gastrointestinal cancer is the most common type of cancer in Europe5 and the most common cause of death among all of the major cancer groups, representing 27% of all cancer deaths3
- around 60,000 new cases of gastrointestinal cancer are diagnosed each year, and the incidence is increasing; they represent 25% of all cancers in men and 20% in women3
- colorectal cancer is the third most common cancer in England and Wales and accounts for 13.7% of all new cancers.3
The UK is currently a poor performer in the European cancer arena.6-10 The International Cancer Benchmarking Partnership found widespread international differences in population-based cancer survival from the 1980s to 2002 in patients diagnosed with colorectal, lung, breast, and ovarian cancer between the six countries studied (selected because of their similar wealth, universal health coverage, and high-quality cancer registration profiles).11 Although overall survival for colorectal cancer has improved, substantial differences remain; for example, survival rates for the UK and Denmark were 8%-10% lower at both 1 and 5 years compared with the other countries—for patients aged 65 years and older, the differences between the UK and other European countries were 10%-15%.11 The causes for these discrepancies are multifactorial and seem to tie the UK in with Denmark, as both have excellent gate-keeper or primary care systems to manage referrals to secondary care (this may actually result in restricted or harder-to-access specialist care and investigations, thus contributing to higher mortality rates).
Despite the significant impact of gastrointestinal disease, it has a relatively low profile as a speciality in the UK, in part due to the lack of a national service framework (NSF), along with the omission of any gastroenterological quality markers in the quality and outcomes framework (QOF) for general practice.12 Recognition and implementation of the points addressed in Box 1 would help to improve the level of care provided to patients with gastrointestinal conditions.
A new direction for the NHS was outlined in the White Paper, Equity and excellence: liberating the NHS, which was published in July 2010.13 This provided a tantalising opportunity to develop innovative ways of working to address the shortfalls within gastroenterology, which, as a specialty, fits each aspect of the NHS Outcomes Framework.14 The Department of Health has already implemented several strategies to address the relevant domains. One is the National Awareness and Early Diagnosis Initiative (NAEDI),15 which will see a 40% increase in endoscopic procedures in the next year.16 Other projects include a pilot of a GP risk-assessment tool for colorectal cancer.17
Proformas for referral have been shown to increase adherence with NICE guidelines and referral does lead to increased diagnosis of cancer;18 however, a review of the significant event audit of upper gastrointestinal cancers has found that the NICE guideline on dyspepsia19 may be having a perverse, double gate-keeping effect on time to diagnoses.18 The NICE guidelines on dyspepsia and referral of suspected cancer date from 2004 and 2005, respectively,19,20 and will be updated in the near future. This is an opportunity to tailor the guidelines to specific populations and to allow more appropriate guidance to enable earlier diagnosis. It may also be worth considering:
- the appropriateness of relying on previously ‘normal’ investigations in patients with persistent symptoms
- an increased emphasis on investigation for early dysphagia in higher-risk groups (not just based on age)
- new-onset dyspepsia in older patients.
Clinical commissioning groups now have the ability to enable direct access to endoscopic testing, which will remove the double gate-keeping effect of both primary care and secondary care delaying the patient pathway to testing. Clinical quality and governance obviously should be at the forefront of such commissioning—not merely cost—nevertheless, now is the right place and time to implement the quality, innovation, productivity, and prevention (QIPP) agenda to elevate the standards, outcomes, and experiences of gastroenterology patients.
|Box 1: Improving care for gastrointestinal conditions|
|QOF=quality and outcomes framework; IBD=inflammatory bowel disease|
Current service design
Endoscopic examination remains the gold-standard test for patients with gastrointestinal problems. This can be offered through a number of referral routes:
- via the 2-week pathway for patients fulfilling the criteria
- to the local acute trust via the outpatient department
- via direct access to the acute trust, if available
- to a community based direct-access service, if available.
Some of these routes are associated with cost and time implications. For example, a patient referred to the local acute trust via the outpatient department will have to wait to be seen in the clinic. They will then be listed for the endoscopy that the referring physician already knew they needed, and so they will have a second waiting period; although units accredited by the Joint Advisory Group (JAG)21 for gastrointestinal endoscopy should have a routine waiting time of fewer than 6 weeks, many units, particularly screening units, are struggling with demand. After the test, the patient may be followed up again in the clinic. The total cost for this will comprise the outpatient department tariff, the full endoscopy tariff, and the follow-up clinic tariff. The direct-access route is clearly more efficient and cost effective, particularly if it is available in the community, where many services will run at subtariff pricing.
Bowel cancer screening
The NHS Bowel Cancer Screening Programme is a service that will identify patients with colonic cancers.22 This programme began in 2006 and is now fully rolled out across the country. People aged 60-69 years are offered screening by faecal occult blood (FOB) testing every 2 years—a colonoscopy is offered if the test is positive.22 This service has been very successful in identifying patients with colon cancers. Approximately 2% of those screened will require a colonoscopy, with take-up rates for the FOB test ranging from 30% to 55% across the country.22,24 The rates of cancer in those having colonoscopy are high (about 10% and, equally importantly, about 40% of patients have polyps);24 these are astounding rates in an asymptomatic population. An age extension means that the service will also be offered to people aged 70-75 years; this is already in place in about one-half of the country.22
The contribution that primary care makes to early cancer diagnosis goes beyond assessment and referral of symptomatic patients, it also involves activity around prevention and screening. As a specialty, gastroenterology has not been addressed by QOF and greater emphasis is therefore needed in increasing the knowledge of primary care staff in this clinical area. Ongoing work in the early diagnosis of certain cancers (including colorectal and upper gastrointestinal tract cancers) is already increasing awareness within the primary care community. Direct access to endoscopic testing for GPs is facilitating early diagnosis. Improved awareness of NICE guidance (on dyspepsia19 and commissioning25) will also allow GPs to improve care within gastroenterology.
Future of screening
Following a study by Atkin et al, which showed that, ‘flexible sigmoidoscopy is a safe and practical test and, when offered only once between ages 55 and 64 years, confers a substantial and long lasting benefit’, 26 all people aged 55 years will be offered flexible sigmoidoscopy.22 This service is planned to start in five centres this year and will then be rolled out across the country. For a population of 500,000, it is expected that 60 flexible sigmoidoscopies would need to be performed weekly, with an extra list of colonoscopies also generated per week. Clearly, this will place a huge demand on an already squeezed service.
Future for endoscopic provision
The QIPP programme strives to transform the NHS by improving quality while saving money. Community endoscopy units can achieve this goal with JAG accreditation, which can be accomplished by community units, being the hallmark of quality for endoscopy units.21 The community service in Braintree, which has been running for many years, attained full JAG accreditation several years ago. Although it can be difficult and expensive to achieve, users of a fully accredited service know that they will receive the best treatment. It is clear that community endoscopy units are needed throughout the country as demand for lower gastrointestinal endoscopy is set to double over the next 5 years.27 It will be difficult to meet this demand with waiting times already under pressure. Direct access to endoscopy is somewhat of a postcode lottery, with not all primary care trusts commissioning community endoscopy services. Clinical commissioning groups will have the power to commission low-cost, high-quality, direct-access community endoscopy units, which will help to pave the way for the future of endoscopic provision.
Improving gastrointestinal care and management appear to be daunting prospects to the cash-strapped NHS; however, the rewards will be immense both for patients and commissioners. Keeping the status quo is not an option; it is time for the new clinical commissioning leaders to develop: both care pathways to diagnose serious pathology promptly with easy and accessible access to diagnostics (endoscopy) and integrated pathways for gastrointestinal long-term conditions. This two-pronged approach will improve outcomes and control costs.
Great Britain won only one gold medal at the Olympics in Atlanta, but the sporting leadership sat down and planned their approach to deliver the London 2012 outcomes. Today’s medical leadership has that same opportunity.
- Gastrointestinal cancers are a major avoidable cause of premature mortality and several national programmes are in place to identify these earlier
- These will stimulate increased referrals and the need for endoscopic investigations
- Commissioners should work with local providers to define local pathways to:
- make this process most efficient
- reduce unnecessary outpatient examinations
- Direct access to endoscopy supported by referral guidelines and decision-support tools will be one way of meeting this challenge
- Tariff prices:a
- gastroenterology outpatients = £265 (new), £83 (follow up)
- upper gastrointestinal endoscopy = £370 (FZ60Z), with biopsy £405 (FZ61Z)
- colonoscopy = £479 (FZ51Z)
- colonoscopy with biopsy = £563 (FZ52Z)
- therapeutic colonoscopy (FZ53Z) = £613.
- British Society of Gastroenterology. Commissioning evidence-based care for patients with gastrointestinal and liver disease. London: 2009.
- Jones R. Primary care research and clinical practice: gastroenterology. Postgrad Med J 2008; 84 (995): 454–458.
- British Society of Gastroenterology. Care of patients with gastrointestinal disorders in the United Kingdom: a Strategy for the future. London: 2006. Available at: www.bsg.org.uk/images/stories/clinical/strategy06_final.pdf
- Lewison G. Gastroenterology in the UK: the burden of disease. London: The Welcome Trust, 1997. Available at: www.bsg.org.uk/pdf_word_docs/burden_disease.pdf
- Ferlay J, Shin H, Bray F et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer 2010; 127 (12): 2893–2917.
- Coleman M, Quaresma M, Berrino F et al. Cancer survival in five continents: a worldwide population-based study (CONCORD). Lancet Oncol 2008; 9: 730–756.
- Berrino F, De Angelis R, Sant M et al. Survival for eight major cancers and all cancers combined for European adults diagnosed in 1995—99: results of the EUROCARE-4 study. Lancet Oncol 2007; 8: 773–783.
- Berrino F, Sant M, Verdecchia A et al, eds. Survival of cancer patients in Europe: the EUROCARE study. IARC Scientific Publications: 132. Lyon: International Agency for Research on Cancer, 1995.
- Berrino F, Capocaccia R, Estève J et al, eds. Survival of cancer patients in Europe: the EUROCARE-2 study. IARC Scientific Publications: 151. Lyon: International Agency for Research on Cancer, 1999.
- Sant M, Aareleid T, Berrino F et al. EUROCARE-3: survival of cancer patients diagnosed 1990–94—results and commentary. Ann Oncol 2003; 14 (Suppl 5): 61–118.
- Coleman M, Forman D, Bryant H et al; ICBP Module 1 Working Group. Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995–2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data. Lancet 2011; 377 (9760): 127–138.
- British Medical Association. NHS Employers. Quality and outcomes framework 2012/13. London: BMA, NHS Employers, 2012. Available at: bma.org.uk/practical-support-at-work/contracts/independent-contractors/qof-guidance
- Department of Health. Equity and excellence: liberating the NHS. London: DH, 2010. Available at: www.dh.gov.uk/en/Healthcare/LiberatingtheNHS/index.htm
- Department of Health. The NHS outcomes framework 2012/13. London: DH, 2011. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131700
- National Awareness and Early Diagnosis Initiative for England (NAEDI) website. info.cancerresearchuk.org/spotcancerearly/naedi/ (accessed 17 July 2012).
- Cancer Research UK. Promoting early diagnosis of breast, bowel and lung cancers.First report 2010/11 local projects. London: DH, 2012. Available at: www.dh.gov.uk/health/files/2012/06/2900105_Cancer_BreastBowelLung_acc2.pdf
- Hamilton W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. Br J Cancer 2009; 101 (Suppl 2): S80–S86.
- Jani A, Jenner L, Ma F et al. Referral proformas improve compliance to national colorectal two-week wait targets: does this impact on cancer detection rates? Colorectal Dis 2012; 23: doi: 10.1111/j.1463-1318.2012.03010.x (epub ahead of print).
- National Institute for Health and Care Excellence. Dyspepsia: managing dyspepsia in adults in primary care. Clinical Guideline 17. London: NICE, 2004. Available at: www.nice.org.uk/guidance/CG17
- National Institute for Health and Care Excellence. Referral guidelines for suspected cancer. Clinical Guideline 27. London: NICE, 2005. Available at: www.nice.org.uk/CG027
- Joint Advisory Group on Gastrointestinal Endoscopy website. www.thejag.org.uk/Home.aspx (accessed 23 July 2012).
- NHS Bowel Cancer Screening Programme website. www.cancerscreening.nhs.uk/bowel (accessed 23 July 2012).
- Hewitson P, Woodrow C, Austoker C; Cancer Research UK Primary Care Education Research Group. Evidence summary: patient information for the NHS bowel cancer screening programme. Sheffield: NHS Cancer Screening Programmes, 2008. Available at: www.cancerscreening.nhs.uk/bowel/publications/nhsbcsp04.pdf
- NHS Cancer Screening Programmes. Guidance for public health commissioners. Sheffield: NHS Cancer Screening Programmes, 2008. Available at: www.cancerscreening.nhs.uk/bowel/publications/nhsbcsp03.pdf
- National Institute for Health and Care Excellence. Upper GI endoscopy service. Commissioning guide. Implementing NICE guidance. London: NICE, 2007. Available at: www.nice.org.uk/media/87F/B6/UpperGIEndoscopyServiceUpdateCommissioningTool.pdf
- Atkin W, Edwards R, Kralj-Hans I et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010; 375 (9726): 1624–1633.
- NHS Diagnostics Improvement website. Endoscopy improvement. www.improvement.nhs.uk/diagnostics/EndoscopyImprovement/tabid/128/Default.asp (accessed July 23 2012). G