Evaluating and implementing better patient-orientated management of chronic Gastrointestinal Disorders in Primary Care

AIM:To improve "whole healthcare " outcomes for the biopsychosocial management of chronic gastrointestinal disorders and to reduce the development of ill health.OBJECTIVES:To implement a novel package of care, the ‘Whole Systems Informing Self-management Engagement (WISE) with a view to reduce persistence of gastrointestinal (GI) symptoms to ensure the more effective use of appropriately targeted services.To engage up to 2700 patients and a range of professionals to use WISE.To assess patient acceptance and choice, cost-effectiveness, the predictors of outcome benefit and patient, professional and organisational responses to implementation.BACKGROUND:Chronic GI disorders, particularly Inflammatory Bowel Disease (IBD) and Functional GI disorders (eg. Irritable Bowel Syndrome and Functional Dyspepsia), are major burdens in primary care. We have improved health and quality of life for over 80% of these patients, in multiple RCTs using education, self-management and psychological support, and shown that psychological distress, and symptom impact on life predict chronicity. These findings, together with an in-depth understanding of expressed patient need, have informed the development of WISE to enhance self-management by, improving patient information, training health professionals to provide support, and improving access to care. Our evidence shows that WISE can work within the existing NHS, however providers need to adapt traditional delivery models, re-orientate professional roles and modify existing practices.IMPORTANCE OF PROPOSED RESEARCH:There are 6 million consultations per year in UK primary care for chronic GI disorders. They are often incurable, of unknown aetiology, high morbidity and healthcare cost, and management is unsatisfactory. In most, psychological illness co-exists which is inadequately managed at present.RELEVANCE TO PRIORITES AND NEEDS OF NHS:The programme is highly relevant because of its focus on long term disease management in primary care, with patient-developed, and patient-centred, self-management plans to address physical and psychological well-being.RESEARCH PLAN:We propose two projects.PROJECT 1.To use WISE for chronic GI disorders and determine how well our RCT results can be reproduced in the "real world", and the factors affecting success.PROJECT 2:To determine how well WISE prevents new onset GI problems from becoming chronic.THE WISE MODEL:To engage patients with WISE, trained practitioners will assess self-management capabilities, and involve them in a choice of low intensity options eg. self-help guidebook, self-management plan, followed by a choice to 'step up' to more intensive patient focussed hypnotherapy or cognitive behaviour therapy.RESEARCH DESIGN:Roll out of WISE will be staged. 40 Practices will be recruited and randomised into two matched groups (A and B).Project 1:All patients with Chronic GI disorders will be offered WISE, starting in year 1 (group A), and year 2 (group B). At 2 years, outcomes for patients in group A will be compared with those in group B. Year 3 data will show whether the impact of WISE on group A is replicated with group B.Project 2:In year 1, group A patients will be offered WISE according to preference. Group B patients will receive care as usual in the first year, and WISE in year 2. In year 3 prospective use of our predictive tool will test whether targeting therapy according to risk of chronicity can improve outcomes in both groups. We predict greater symptom resolution in patients receiving WISE.OUTCOME MEASURES:Clinical: consultation rates, clinical global impression score, disease severity scores.Health economic: patient use of primary and secondary care, community health and social care.Patient and Organisational acceptability: Qualitative interviews to explore, choice, coping skills, and engagement of patients and health professionals.PATIENT INVOLVEMENT:Salford’s GI Patients Forum, who designed and evaluated our previous studies, remains involved t