Influencing national policy to improve service delivery and patient care in gastroenterology
Following an analysis of our clinical workload and waiting times in gastroenterology we concluded that new measures are needed to ensure timely and appropriate management of patients with gastrointestinal disorders, particularly inflammatory bowel disease and gastrointestinal bleeding. For inflammatory bowel disease, which is a chronic disorder characterised by unpredictable relapse, we proposed an open access service to enable patients to be reviewed at an appropriate time when suffering a flare-up of their disorder, and we explored the clinical- and cost-effectiveness of this in a randomised controlled trial. We showed that open access resulted in fewer outpatient visits, was preferred by patients and general practitioners, and did not adversely affect patient outcomes. We also concluded that to work effectively open access needs a nurse trained in inflammatory bowel disease as the first point of contact in order to be able to make a sensible triage decision. This evidence has led to the widespread adoption of open access follow-up in inflammatory bowel disease.
When we introduced specialist nurses routinely in clinical practice we wished to make the post as attractive as possible and offered in parallel training in endoscopy, at a time when in the majority of hospitals these procedures were exclusively undertaken by doctors. To evaluate the clinical- and cost-effectiveness of nurses undertaking endoscopy we conducted the first and only randomised controlled trial comparing nurse and doctor endoscopy, which showed that outcomes following endoscopy by nurses were no different from those following endoscopy by doctors but that nurses were significantly more thorough than doctors in examining the oesophagus and stomach, and in record-keeping. Furthermore patients were more satisfied following endoscopy by nurses.
In other studies we have analysed routinely collected data from England and Wales to show that when patients with inflammatory bowel disease require admission on an unplanned basis, and are ill enough to require removal of the colon, the mortality is much higher than if this is done as a planned procedure. Furthermore, after three years, patients who do not undergo colectomy have a higher mortality than those who have undergone colectomy, again at three years. This evidence has led to considerable debate and change in practice regarding the frequency and timing of colectomy in inflammatory bowel disease, particularly ulcerative colitis. Combined with the evidence for specialist nurses providing open access follow-up we have witnessed a dramatic rise in the number of specialist nurses undertaking both endoscopy and the specialist follow-up of patients with inflammatory bowel disease.
Our analysis of routine data has also confirmed the higher mortality in patients who are admitted unexpectedly at weekends or bank holidays, in this case with upper gastrointestinal bleeding. This has led to recommendations from the British Society of Gastroenterology and Royal College of Physicians for services out-of-hours for patients with upper gastrointestinal bleeding.