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Our business plan for Barrett's disease

Our business plan: an outline business case for transferring the management of patients with Barrett’s disease to primary care, prepared by the Pan Croydon PBC group

Our business plan: an outline business case for transferring the management of patients with Barrett's disease to primary care, prepared by the Pan Croydon PBC group

Explanation of Barrett's disease and current practice

Barrett's disease is a condition that gives a patient a small but real increased risk of developing oesophageal cancer over their lifetime. Because of this, a surveillance programme for trying to screen has been developed. The current pathway is outlined below.

OGD at year one where diagnosis is made £397
Follow-up OP at year one £80
OGD F/U at one year £397
F/U OP at one year £80

Subsequently there follows a three-year cycle

Year 1 OP F/U £80
Year 2 OP F/U £80
Year 3 F/U OGD £397
Year 3 F/U OP £80
Total for a three-year cycle per patient £637

Justification for changing the follow-up pathway

The effectiveness of the current programme has never been established in any clinical trial and a meta-analysis has recently shown that patients may suffer harm due to the side-effects of the OGD. Locally we have not saved a life after nearly 20 years of surveillance through the early diagnosis of a cancer. Continuing may cause more harm than good.

We propose a new pathway. After the first-year follow-up OGD (provided there has been no significant progression) all further follow-up should be in primary care.

Explanation of the new pathway

Once a person with Barrett's disease has had the first annual OGD it is proposed they are followed up with an annual structured interview. This is analogous to the current hospital outpatient service.

The interview will ask whether the patient has:

• reflux symptoms
• dysphagia
• weight loss
• loss of appetite
• any other concerns

There will also be an annual FBC to screen for occult blood loss.

Benefits of the programme

Care closer to home

• Better patient education and continuity of care
• Agreed screening questions

Better quality

• Symptom control, compliance and prescribing all linked
• All patients to receive full proton pump inhibitor therapy

Improved equity

• All Barrett's disease patients to be monitored on practice register
• Reduced risk of side-effects from surveillance programme

Improved clinical governance

• Practices to maintain a register and record annual FBC and review

Much better value for money

• It is proposed that practices be paid £50 a year per patient for carrying out this programme. A full three-year cycle would then cost £150 plus the cost of three FBC blood tests – say a maximum of £156. The saving per patient over three years is about £481 or £160 a year per patient.

Enabling 18-week target

• Reduce number attending OP
• Free staff to carry out investigative procedures

Improving diagnostic waits

• Reduce routine follow-up OGD wait

Risk of not introducing the programme

The numbers of patients with Barrett's disease will continue to rise. The burden on our local trust and the expense will continue to rise inexorably. This may be justifiable and sustainable if the programme showed significant health benefit. Not only is this not the case, but the opposite may be true.

Way forward

We ask the PCT to support the plan in theory. We would like to set up round-table discussions with our hospital colleagues to further refine and agree on the pathway and develop an integrated pathway.

This would focus on each party's responsibilities. The PCT is asked to support the development of a LES to pay for non-core GP activity. We would also ask that all parties work together to develop an implementation and training plan in both primary and secondary care.

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