Tools and resources

Adoption support resource – insights from the NHS

7 How to implement NICE's guidance on faecal calprotectin tests for inflammatory diseases of the bowel

7 How to implement NICE's guidance on faecal calprotectin tests for inflammatory diseases of the bowel

The experiences of the 2 NHS trusts who took part in NICE's adoption project have been used to develop practical suggestions for how to implement NICE guidance on faecal calprotectin diagnostic tests for inflammatory diseases of the bowel.

Project management

It is the experience of the Health Technologies Adoption Programme that in order to gain maximum benefit, this technology should be adopted using a project management approach.

NICE has produced the Into practice guide, which includes a section on what organisations need to have in place to support the implementation of NICE guidance.

Project team

The first step in this approach is to form a local project team who will work together to implement the technology and manage any changes in practice.

Individual NHS organisations will determine the membership of this team and how long the project will last. In order to implement this guidance in an effective and sustainable way, consider the following membership of the team:

  • Clinical champion(s): could be a consultant gastroenterologist, directorate manager or GP with an interest in gastroenterology. They should have the knowledge and understanding to be able to drive the project, answer any clinical queries and champion the project at a senior level.

  • Project manager: could be someone in a clinical or managerial role and will have responsibility for the day‑to‑day running of the project, coordinating the project team and ensuring the project is running as planned.

  • Management sponsor: will be able to help assess the financial viability of the project, drive the formulation of a business case and help to demonstrate the cost savings achieved.

  • Other stakeholders or staff: these may include laboratory staff or staff working in the local clinical commissioning group who will be valuable members of the project team because they will be involved in providing the service.

Some of the early questions that the implementation teams involved in this project considered were:

  • Which technology will be selected and why; laboratory‑based or near patient faecal calprotectin test?

  • Where will the funding come from?

  • How will local metrics be identified and measured?

  • Who will be responsible for collecting the clinical data?

  • How will issues surrounding information governance be addressed?

  • How will the necessary education or training be provided?

  • Are there any obvious challenges and how can these be overcome?

  • How can effective communication with all involved be ensured?

  • How long should the follow‑up period be for those patients who have a negative faecal calprotectin test?

  • At what point and how should GP feedback be evaluated?

  • How should patient experience data be collected?

  • How can awareness of faecal calprotectin testing be raised in primary care?

Communication and collaborative working

Experience shared by NHS sites has indicated that when implementing faecal calprotectin testing in primary care, it is important that there is clear and wide communication between all stakeholders. This will include the gastroenterology department, laboratory staff, managers and primary care providers. The communication strategy for the project should be considered alongside planned educational activities.

The specific communications may include information on the following:

  • Local rationale for using faecal calprotectin testing.

  • An explanation of the reporting results and actions to be taken.

  • The needs and arrangements for clinical audit.

  • Who to contact for further information and how to report problems.

Measuring success

In order to demonstrate the benefits of adopting faecal calprotectin testing it is important to collect data before, during and after implementation. Some of these measures will not routinely be collected, and consideration will need to be given to the data‑collection methodology appropriate to the service. Suggested measures from the sites involved in developing this resource are:

  • number of patients presenting to GP with lower‑abdominal symptoms

  • number of patients with negative or low faecal calprotectin test results

  • number of patients with indeterminate faecal calprotectin test results

  • number of patients with positive or high faecal calprotectin test results

  • number of patients diagnosed with irritable bowel syndrome (IBS)

  • number of patients diagnosed with IBS referred on for gastroenterology specialist assessment

  • number of patients with suspicion of inflammatory bowel disease (IBD)

  • number of patients with suspicion of IBD referred for gastroenterology specialist assessment

  • number of colonoscopy/sigmoidoscopy/endoscopy procedures undertaken.

Clinical coding

Read codes are the standard clinical technology system used in general practice in the UK. The Read codes are designed to support a fully computerised clinical record of each patient encounter. Codes for abdominal pain, diarrhoea and constipation are often used by GPs for IBS and the IBS diagnostic Read code is rarely used in practice. This has led to a large underestimate of the prevalence of IBS in the community. Sites wishing to implement faecal calprotectin testing into primary care will need to establish the local clinical coding practice.

Table 6 shows the most recent Read codes (released October 2014) relevant for faecal calprotectin testing and IBS diagnosis.

Table 6 Read codes for faecal calprotectin testing and IBS diagnosis

J5211

Irritable bowel syndrome characterised by constipation

J5212

Irritable bowel syndrome characterised by alternating bowel habit

47J0

Faecal calprotectin test indeterminate

47J1

Faecal calprotectin test invalid

47J2

Faecal calprotectin test positive

47J3

Faecal calprotectin test negative

It may be desirable to code patient encounters to 1 of the national statistical classifications such as ICD‑10, because this may help with data collection and analysis when looking at both primary and secondary care data. Although there are no ICD‑10 codes that could be cross‑mapped for faecal calprotectin testing, it is possible to cross‑map diagnoses of IBS and IBD using the Read codes shown in table 7.

Table 7 Read codes available for IBS and IBD

XE0as

Irritable bowel syndrome

XabiQ

Irritable bowel syndrome characterised by alternating bowel habit

XabiP

Irritable bowel syndrome characterised by constipation

X305z

Irritable bowel syndrome variant of childhood

X3060

Irritable bowel syndrome variant of childhood with diarrhoea

X3061

Irritable bowel syndrome variant of childhood with constipation

J5210

Irritable bowel syndrome with diarrhoea

XE0ae

Inflammatory bowel disease

X7021

Juvenile arthritis of inflammatory bowel disease

X702C

Seronegative arthritis secondary to inflammatory bowel disease

XSE1V

Idiopathic chronic inflammatory bowel disease

Further information about Read Codes and cross mapping is available from the Health & Social Care Information Centre.

Overcoming implementation hurdles

The implementation challenges reported by the 2 NHS sites using faecal calprotectin testing in primary care are set out in table 8.

Table 8 Reported implementation challenges when using faecal calprotectin testing in primary care

Implementation challenge

Solution

Capturing and measuring appropriate data from both primary and secondary care to demonstrate the impact of faecal calprotectin testing.

Use of appropriate Read codes and ICD‑10 codes.

Ensure accuracy of coding data at trust level.

Obtain good‑quality GP and patient feedback.

Clinical confidence

Select appropriate metrics to demonstrate cost and clinical benefits, safety and demand.

Provide adequate training, information and evidence base for testing.

Risk management

Securing engagement from primary and secondary care can be challenging and can pose a significant risk to successfully completing the project.

Ensure that there is an effective communication plan in place to help stakeholders become and remain engaged with the project through to fruition.

Financial resources

Securing the necessary funding may need a collaborative approach from both primary and secondary care.

Balance consideration of the loss of income from reduced referrals for gastroenterology specialist assessment against the potential to reduce endoscopy waiting lists for secondary care.

Developing a business case

Resource impact

Laboratories at each of the project sites secured additional funding to enable them to order the consumables needed for faecal calprotectin testing for primary care referrals during the pilot.

Both were already offering faecal calprotectin testing following secondary care referral, so the service infrastructure was already in place. Following evaluation of the project data, it may be necessary for both laboratories to prepare business cases to secure long‑term funding for their pathology budget if they plan to extend faecal calprotectin testing to the whole of their primary care catchment areas.

Each of the laboratories involved in the project negotiated the costs of the tests with their respective suppliers. It is expected that if their use of faecal calprotectin tests increases significantly, these costs will be reconsidered.

Business case

The implementation team should treat the development of a robust business case as an early priority in the life of the implementation project.

Local arrangements for developing and approving business plans will vary from trust to trust and each organisation is likely to have its own template and process in place. The organisations involved in the development of this resource advised NICE on the development of a template business case for faecal calprotectin.

Developing local documentation

The following are examples developed by NHS organisations using faecal calprotectin testing in primary care that can inform the development of local documentation.

Guidelines and algorithms:

Audit templates:


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