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The Importance of Primary Care and the Development of Flare Pathways for Inflammatory Bowel Disease

“Primary Care is the bedrock of the NHS” is a phrase that is oft quoted, and we all appreciate the value that we get from a state-funded, free-at-the-point-of-access health care system. https://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror-wall-2014-update-how-us-health-care-system. However, the NHS is starting to creak at the seams with increasing treatment availability, an ageing population, and increasing multimorbidity. The recent Nuffield Trust report commissioned by the BBC has highlighted a sustained fall in the number of GPs working in England, triggered in part by the increasing workload and long working hours that show no sign of relenting. https://www.nuffieldtrust.org.uk/news-item/is-the-number-of-gps-falling-across-the-uk#checking-the-vital-signs-for-general-practicePalmer W (2019) “Is the number of GPs falling across the UK?” Nuffield Trust blog, 08 May.

However, almost all GPs still enjoy the work that they do; the long-term relationship with their patients, the opportunity to manage patients with a huge variety of medical problems, and the impact that they can have on the lives of their patients and their families.

The relationship with secondary care is interesting. Over the last fifteen years there has been a rapid rise in the number of consultants working in hospitals as the service has moved from being consultant-led to being consultant-delivered. This, together with the reduced opportunity to meet at lunchtime educational events that post-graduate medical centres used to offer routinely, has meant that the days when GPs knew who they would refer to for a particular issue have gone. Instead we are more likely to refer our patients to a faceless triage system where we do not know where the patient will end up. This system has advantages: patients should see the most appropriate clinician in a timely manner and are less likely to spend time bouncing back and forth between sub-specialists until they meet one who can deal with their problem. However, it has opened the divide between GPs and our secondary care colleagues. Moving consultants to work in community-based settings is helping to re-establish this relationship, but gastroenterology is lagging behind other areas such as diabetes, paediatrics, dermatology and respiratory medicine.

The 2019 IBD Standards has a number of key points to improve communication between Primary and Secondary Care, including the production of a care plan for each patient that should include individualised guidance to help manage flares, and contact details for the Clinical Specialist Nurses who can help bridge the gap and provide rapid access and advice to patients and GPs. https://crohnsandcolitis.org.uk/support/find-an-ibd-nurse-specialist is an interactive map to help locate this advice, but the UK does not yet have a sufficient number of IBD nurses to provide the level of service required.

In order to help Primary Care support their patients, the Royal College of General Practitioners and Crohn’s and Colitis UK have co-produced a pair of flare-management pathways that have been endorsed by the RCGP, the Primary Care Society for Gastroenterology, and the British Society for Gastroenterology. These are a rapid guide to identifying and managing flares where patients do not have care-plans or advice is not easily available from the secondary care services. The pathways can be found on the Spotlight Project Toolkit, www.rcgp.org.uk/ibd, along with advice to help GPs diagnose and support their patients with Crohn’s Disease or Ulcerative Colitis.