St Helens Clinical Commissioning Groups (CCGs)

Review of the gastrointestinal pathway with a focus on upper and lower endoscopy pathways

RightCare works with local health systems to identify innovative practice and share learning. Information briefs are a way of communicating early views of emerging practice. They are designed to raise interest and demonstrate good practice in the development of transformative change across the country.


  • RightCare intelligence data has helped identify opportunities to improve the gastroenterology pathway in St Helens CCG – the CCG had amongst the highest scope rates in England.
  • Working across the health system, the CCG has redesigned both the upper and lower scope pathways by the introduction of pre-referral testing and the use of electronic referrals through a referral gateway with clinical triage.
  • In the four months from December 2017 to end March 2018, the CCG has seen a reduction of 535 inappropriate scopes, avoiding patients undergoing invasive procedures; improving patient experience and resulting in a net reduction in spending of £205,000.

Diagnose – what’s the problem?

  • RightCare Intelligence data identified both outcome and quality opportunities for St Helens CCG in the gastrointestinal pathway.
  • The local health systems formed a multidisciplinary team of primary, community and secondary care clinicians with system managers and intelligence analysts. The task was to review data and diagnose the local issues.
  • Looking at the data in detail highlighted individual procedures and approaches where the local health system were national outliers.
  • The team identified that changing the way the pathway worked would lead to appropriate treatment practices and reduced unnecessary use of resources.

Develop – what they changed

  • The local health system updated the dyspepsia and irritable bowel syndrome (IBS) clinical pathways.
  • The following decisions were made as part of the pathway re-design:
    • Pre-referral testing – mandated the use of faecal calprotectin testing for lower scopes and helicobacter testing for upper scopes.
    • Development of local referral protocols for primary care – developed localised Map of Medicine maps for GPs to follow, including completion of the tests above. St Helen’s developed dyspepsia and IBS Maps. These Maps were developed in conjunction with the Healthy Living Team, medicines management, GPs and the local acute Trust consultant.
    • Establishment of the use of electronic referrals through a referral gateway with clinical triage. Tick box direct access referral forms were withdrawn and replaced with an electronic referral form. Referral forms are now routed via the Referral Management System. An external triaging partner was commissioned, and all other referral pathways were closed.

Deliver – What does the local health system say changed

  • Following the initial discussion of the data in late 2016, the new pathways commenced across the CCG on 4 October 2017.
  • The initial impact of reductions was expected to be evident in December 2017, due to clearance of existing referrals already in the system.
  • The pathway redesign reached full implementation in December 2017 and by the end of 2017/18 the CCG had seen a reduction of 535 endoscopic procedures compared to 2016/17. This equates to a reduction of £205,000 in spend over the financial year.
  • An average of 95 helicobacter tests has been performed per month since November 2017. Clearance time for these tests has improved from 30 days to seven days which gives GPs confidence in the process.
  • An audit of the triage function was performed to ensure adherence to the pathways.
  • Key quality benefits for patients were not having an invasive procedure, avoiding travelling to hospital and the anxiety associated with having a hospital procedure. A positive Helicobacter result can be treated with antibiotics.

What next? – learning points from the local system

  • Ensure that data is reviewed by a multi-disciplinary group to ensure no false conclusions are drawn. Engage with all partners in the pathway.
  • Triangulate several data points e.g. pathway views, tests requested, referral deflections etc. This will enable you to spot issues across GP practices. E.g. a practice that is not viewing the map may also have low test requests.

With thanks to:

  • Kerry Ingham, Senior Performance and Programme Manager, NHS St Helens CCG
  • Nina Russell, Delivery Partner, RightCare
  • Dr Hilary Flett, GP and Governing Body member, St Helens
  • Dr Ash Bassi, Divisional director Gastroenterology, St Helens and Knowsley Hospitals

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