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BSG Webinar: Looking after our out-patients – challenges and opportunities

This webinar, recorded on the 29th September 2020, featured talks on the changing landscape of out-patient work in gastroenterology from both a primary and secondary care perspective, as well as the challenges and opportunities for training.

This webinar was chaired by BSG President Elect Dr Andy Veitch, and featured discussion from CSSC Chair Dr Andy Douds.

The view from Secondary care – Dr John Thomson

The view from Primary care – Dr Kevin Barrett

Training our juniors in the new OP landscape – Dr Bev Oates

This webinar has been approved by the Federation of the Royal Colleges of Physicians of the United Kingdom for 1 category 1 (external) CPD credit. You can access this credit by filling out this short feedback form. In line with RCP guidance, this will be available for four weeks after the date of the original broadcast on 29th September 2020.

Questions from the webinar

The view from Secondary Care

Excellent idea to have combined virtual clinics, but what do you propose for those patients that are not computer literates or have no access to the technique?

John Thomson: Firstly I would advocate that as COVID disappears, digital interactions with Health Services are the patient’s choice. Our work pre-COVID has shown that, generally, patients are good at deciding if the consultation is suitable for video.

There however is a definite gap for those in our society that are not yet digitally connected but we have found in reality this is often less than the perceived gap, for example, a relative or friend may help in the same way they would take them to the physical appointment. Pre COVID, as we already had a video clinic service established, we were expanding successful pilots of community hubs (quiet private spaces in libraries, health centres or other community-building where patients could connect from). Since COVID, distancing measures have meant this is not possible. However, in each of the 4 nations, there have been different initiatives to provide equipment where it’s needed. There is a good equality impact assessment as part of the public consultation on Attend Anywhere (Branded Near Me in Scotland).

Would e-Prescribing from hospital to community pharmacies save some of the push-back of work into primary care?

John Thomson: Yes, that is the intention, aiming to provide information to primary care that a drug has been prescribed but not expect primary care to have to create that initial script. Here is some more information on NHS Grampian’s trial of the CoPPr prescribing system.

It is in its infancy but has been very popular across sectors and will evolve. The ideal future would be a single drug record across sectors but that is quite a way off yet. I do think that this is just part of the picture though, and we need to bridge that chasm between sectors which will include the community investigation hubs and e-prescribing as keystones.

How would you involve patients in redesigning services?

John Thomson: Most Trusts have access to a group of patients who have volunteered for this type of project, it often not that publicised with the clinicians so it may you some time to track down how to access in your particular locality. In addition, national charities often can help with an established local group or access to their members to participate. Future health and wellbeing have some good examples. A word of caution in your planning is to be aware of potential bias in opinions and try to ensure the patients involved are representative across your service. To get those wider views, consider using surveys or even pop up events in shopping centres.

The view from Primary Care

What about management targets such as new / return ratios and discharge rate?
Kevin Barrett: These targets are becoming less relevant now that we are moving towards Integrated Care Systems that have shared targets and shared budgets. I agree that those metrics aren’t always helpful, and can drive inappropriate patient care. This is an example of the clinical voice carrying weight and why we should be involved in commissioning.

Do we now feel that physical examination in Gastroenterology is now almost extinct?

Kevin Barrett: Not at all. Abdominal palpation and a rectal examination are still in NICE NG12 and seeing the patient face to face (or mask-to-mask) can reveal subtle jaundice that may not be visible on a video consultation. This is especially true when consulting patients who we don’t previously know.

Is there a role for combined virtual clinics with primary and secondary care focussing on difficult patients?

Kevin Barrett: Yes, definitely. MDTs with multi-professional input for complex patients are very useful. Remote technology allows them to happen more readily. These joint consultations enable a clear consistent message to be sent to “difficult” patients and can stop them playing one of us off against the other.

Training our juniors in the new landscape

How do these ideas extend to trainees who are rotating through Gastro? I am doing a 4 month rotation and feel like I am not getting enough experience to make a decision about pursuing gastro as a career.

Bev Oates: I presume you may be an IMT trainee, if you are rotating through gastro? The JRCPTB acknowledged that trainees progress should not be impacted by COVID.  A specific commitment was made that there would not be a focus on numbers (e.g. clinics, procedures) for the duration of the trainee’s programme and they would not be expected to make up these numbers at a later date. With the focus on numbers removed, it should instead enable trainers to focus on the quality of review with a trainee. Hopefully, even if you end up seeing fewer patients virtually than you would have done in a face-to-face clinic if you can ensure time is allocated for clinical discussion, evaluation and feedback from your trainer you may find the learning is more valuable. I suggest you discuss your concerns with your supervisor who may be able to help you seek out more gastro opportunities during your attachment. You already managed to seek out our BSG webinar! It is a great speciality, so I would definitely recommend it as a career.

Do you feel that a reliance on Telemedicine will result in over-investigation of patients (ie invasive procedures)?

Bev Oates: I don’t think so personally. Looking at some of the evidence in the literature it appears that telephone and video consultations may, if anything, be a bit shorter and more focused on one area compared to traditional face to face clinics. That may mean we are less likely to go off on a tangent and start uncovering more symptoms or problems to investigate.

Do you think that trainees should have an extra year of training to be added to their programme?

Bev Oates: I do not think this should be the default position. I think as trainers, programme directors and leaders we need to adapt the training provided to enable trainees to acquire the required competencies in a shorter training window. As we discussed in the webinar there is so much we can do to improve training in the new landscape we find ourselves in. We just need to think differently and harness 21st century technology into training.