Quality standard
Quality statement 5: Referral to a specialist service
Quality statement 5: Referral to a specialist service
Quality statement
Adults with persistent, unexplained dyspepsia or reflux symptoms have a discussion with their GP about referral to a specialist service.
Rationale
Long‑term symptoms can negatively affect an adult's quality of life, so they should have a discussion with their healthcare professional about possible referral to a specialist service based on their individual risk factors and preferences. A referral to a specialist service will enable treatment and potential causes to be reviewed in order to reduce symptom burden. It could also reduce the risk of further complications developing, such as scarring of the oesophagus and pylorus, oesophageal stricture, pyloric stenosis and Barrett's oesophagus, which is a risk factor for cancer.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that adults with persistent, unexplained dyspepsia or reflux symptoms have a discussion with their GP about referral to a specialist service.
Data source: Local data collection.
Process
Proportion of adults presenting with persistent, unexplained dyspepsia or reflux symptoms with a recorded discussion with their GP about referral to a specialist service.
Numerator – the number in the denominator with a recorded discussion with their GP about referral to a specialist service.
Denominator – the number of adults presenting with persistent, unexplained dyspepsia or reflux symptoms.
Data source: Local data collection.
Outcome
a) Incidence of Barrett's oesophagus.
Data source: Local data collection.
b) Incidence of oesophageal stricture.
Data source: Local data collection.
c) Incidence of pyloric stenosis in adults.
Data source: Local data collection.
d) Patient‑reported health outcomes for people with dyspepsia or reflux symptoms.
Data source: Local data collection.
What the quality statement means for different audiences
Service providers (general practices) ensure that processes are in place so that adults with persistent, unexplained dyspepsia or reflux symptoms discuss referral to a specialist service.
Healthcare professionals (GPs) discuss referral to a specialist service with adults with persistent, unexplained dyspepsia or reflux symptoms.
Commissioners (NHS England area teams) ensure that they commission services that ensure that GPs discuss referral to a specialist service with adults with persistent, unexplained dyspepsia or reflux symptoms. Commissioners should also ensure that a suitable specialist service is available.
Adults with unexplained indigestion or heartburn that does not go away should talk to their GP about the possibility of being referred to see a specialist.
Source guidance
Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. NICE guideline CG184 (2014, updated 2019), recommendation 1.11.1 (key priority for implementation)
Definitions of terms used in this quality statement
Persistent unexplained dyspepsia or reflux symptoms
Symptoms that have not led to a diagnosis being made by the healthcare professional in primary care after initial assessment (including history, examination and any appropriate primary care investigations such as endoscopy or Helicobacter pylori test). Symptoms have continued beyond a period that would normally be associated with self‑limiting problems. [NICE's guideline on suspected cancer and expert opinion]
Discussion about referral to a specialist service
The discussion should focus on the person's preferences and their individual risk factors (long duration of symptoms, increased frequency of symptoms, previous oesophagitis, previous hiatus hernia, oesophageal stricture or oesophageal ulcers, or male gender). If people have had a previous endoscopy and there is no change in symptoms, discuss continuing management according to previous endoscopic findings. [NICE's guideline on gastro-oesophageal reflux disease and dyspepsia in adults, recommendations 1.3.4 and 1.6.11]
Specialist service
A consultant‑led medical or surgical service. [Adapted from NICE's full guideline on gastro-oesophageal reflux disease and dyspepsia in adults, review question 4.9.1]