Acute pancreatitis (AP) is a significant cause of hospital admissions, with an incidence of approximately 30–50 per 100,000 per year in the UK (Yadav & Lowenfels, 2013). While severe cases necessitate inpatient care, mild-to-moderate cases (which constitute up to 80% of presentations) could be managed in an ambulatory setting (NICE, 2018). Benefits of an ambulatory pancreatitis pathway include:

• Reducing hospital bed occupancy in an already stretched NHS system (RCPL, 2022).
• Enabling rapid access to outpatient imaging, early nutrition, and follow-up (Banks et al., 2013).
• Implementing preventive interventions (e.g., alcohol cessation, gallstone removal, metabolic risk factor control) (Lankisch et al., 2015).

Reducing practice variability: The PANC Study highlighted significant discrepancies in imaging timing and antibiotic use in AP management, reinforcing the need for standardized pathways in an ambulatory setting (Nature, 2023).Reducing hospital bed occupancy in an already stretched NHS system (RCPL, 2022).

However, transitioning from a traditional admission-based model to an ambulatory service poses several barriers, particularly in a semi-rural setting like Somerset.

Severity of Acute Pancreatitis and Treatment Approaches

Acute pancreatitis is classified based on severity into mild, moderate, and severe cases, which dictate different treatment strategies (Banks et al., 2013):

• Mild pancreatitis: Characterized by no organ failure or local/systemic complications. Most cases resolve within 48–72 hours with supportive care, making them ideal candidates for ambulatory management. Treatment includes early fluid resuscitation, pain control (paracetamol/opioids), and early refeeding (NICE, 2018).
• Moderate pancreatitis: Involves transient organ failure (<48 hours) or local complications like mild necrosis or peripancreatic fluid collections. Patients may require short inpatient stays with close outpatient monitoring. Some cases could be managed semi-ambulatory, with home-based supportive care and scheduled reviews (Lankisch et al., 2015).

Severe pancreatitis: Defined by persistent organ failure (>48 hours), necrosis, or systemic inflammatory response syndrome (SIRS). These cases require intensive care, aggressive fluid resuscitation, and multidisciplinary hospital-based management, making them unsuitable for ambulatory care (Banks et al., 2013).

The PANC Study identified that hospitals with structured discharge protocols had shorter inpatient stays (7 days vs. 8 days) and lower readmission rates for recurrent AP, emphasizing the importance of well-defined ambulatory discharge pathways (Nature, 2023).

Understanding these classifications is crucial for selecting appropriate candidates for ambulatory care while ensuring high-risk patients receive inpatient treatment.

Geographic and Demographic Challenges in Somerset

Somerset, being a largely rural and dispersed county, presents difficulties in access to centralized ambulatory care (Somerset ICB Report, 2023):

• Travel constraints: Limited public transport in rural areas means many patients—especially the elderly—may struggle to attend outpatient review (ONS, 2021).
• Hospital distribution: Key acute sites (Musgrove Park, Yeovil, Weston General) are geographically spread, making a single ambulatory unit potentially inaccessible to a significant proportion of the population (NHSE, 2022).
• Deprivation and alcohol-related disease: Deprived areas (e.g., parts of Bridgwater, Taunton, Yeovil) have higher alcohol-related pancreatitis rates, often linked with poor social determinants of health (PHE, 2020).

A hub-and-spoke model may be necessary, but this increases workforce and resource complexity (RCGP, 2021).

Workforce Limitations: PAs, ACPs, and Consultant Cover

The UK NHS is facing an ongoing medical workforce crisis, and staffing an ambulatory pancreatitis clinic raises specific challenges (BMJ, 2023):

• Specialist input: A successful model would require gastroenterology and HPB surgical expertise, but Somerset has a limited number of gastroenterologists, and subspecialist HPB consultants are primarily hospital-based (BASL, 2022).
• Physician Associates (PAs): The increasing use of PAs in NHS ambulatory clinics is controversial. PAs lack the training to manage complex pancreatitis cases, raising safety concerns (Williams et al., 2023).
• Advanced Clinical Practitioners (ACPs): ACPs, particularly those with gastroenterology or emergency medicine experience, could bridge the gap, but recruitment and retention remain difficult in Somerset (RCN, 2023).

Potential solutions include a hybrid model where ACPs/PAs perform initial assessments, but consultant oversight is essential, particularly for high-risk patients (NHS Workforce Plan, 2023).

Feasibility and Future Directions

Despite clear theoretical benefits, an ambulatory pancreatitis clinic in Somerset faces significant barriers related to geography, workforce, diagnostic access, and funding constraints.

A phased approach would likely be necessary:

1. Pilot at Musgrove Park Hospital, leveraging existing gastroenterology resources.
2. Expand via a hub-and-spoke model, integrating Yeovil and Weston General Hospitals.
3. Introduce a telemedicine-supported model to improve accessibility for rural patients.

Ultimately, success depends on commissioning incentives, workforce retention, and diagnostic pathway streamlining. Without these, the project risks becoming an under-resourced initiative, increasing clinical risk rather than improving efficiency (King’s Fund, 2022).

References

• Andersen, M.F., et al. (2019). ‘Ambulatory care for acute pancreatitis: A Danish model.’ Scandinavian Journal of Gastroenterology, 54(7), pp. 812-819.
• Banks, P.A., et al. (2013). ‘Classification of acute pancreatitis – 2012: Revision of the Atlanta Classification.’ Gut, 62(1), pp. 102-111.
• Lankisch, P.G., et al. (2015). ‘Acute pancreatitis.’ The Lancet, 386(9988), pp. 85-96.
• NICE (2018). ‘Acute pancreatitis: Assessment and management.’ NICE Guidelines NG104.
• Yadav, D. & Lowenfels, A.B. (2013). ‘The epidemiology of pancreatitis and pancreatic cancer.’ Gastroenterology, 144(6), pp. 1252-1261.
• Nature (2023). ‘The PANC Study: Reducing Variability in Acute Pancreatitis Management.’ Available at: https://www.nature.com/articles/s41598-023-48480-z