Diagnostics
Calls for improved identification of GORD
Professor Anthony Hobson says it’s time to rethink how we manage Gastro Oesophageal Reflux Disease (GORD), a condition where patients often receive long-term PPIs without diagnostic confirmation. Professor Hobson urges NHS leaders to adopt newer, community-based tests that identify high-risk patients and prevent repeat referrals. Smarter diagnostics could ease endoscopy backlogs and improve NHS efficiency.
Prevalence of proton pump inhibitor (PPI) use is about 15% of the UK population, with prescriptions for England alone estimated to cost NHSE about £190 million.1
Despite
widespread PPI prescribing, the majority of patients have no recorded indication, and most have never had a diagnostic test.2
With NHS
budgets stretched and reflux a key risk factor in developing Oesophageal cancer, it’s time to rethink how we identify Gastro Oesophageal Reflux Disease (GORD), ensure diagnostic accuracy and manage patients more efficiently.
The GORD paradox GORD is one of the most commonly treated Gastro-Intestinal (GI) conditions and yet for the vast majority of UK patients, they are treated without any diagnostic confirmation. NICE guidelines favour symptom-led treatment, but this approach risks missing structural disease and delaying intervention. Without diagnostics, conditions like Barrett’s oesophagus or early malignancy oesophageal cancer may go undetected. We’re treating symptoms, not patients - and losing the chance to prevent serious complications. As NHS England’s 2025 mandate calls for a
shift from hospital to community care, and from sickness to prevention, GORD management must evolve to reflect that ambition: prioritising early identification, diagnostic clarity and long- term risk reduction.3
With rapidly advancing
diagnostics in the field, there has never been a better time to address this.
The PPI problem Proton pump inhibitors (PPIs) remain one of the most overprescribed drug classes in the UK. In 2022–23, over 73 million PPI prescriptions were issued in England alone, with nearly 40% of patients continuing treatment for over a year (and, in my clinical practice, I see patients who have been on PPIs for several years – even decades).2
A patient tests for small intestinal bacterial overgrowth with the SIBO breath test Long-term use has been linked to adverse
outcomes including fractures, Clostridium difficile infection, changes in the gut microbiome and hypomagnesaemia, prompting renewed scrutiny across the NHS.4 NHS Wales has taken a proactive stance, embedding PPIs (alongside opioids) as drugs with clear targets to reduce prescriptions and improve safety. These indicators reflect a broader shift toward medicines optimisation and deprescribing across devolved nations.5 Despite NICE guidance recommending
step-down or on-demand PPI use for most, clinical inertia remains a major barrier. A recent BJGP Open study found that 62% of patients on long-term PPIs had no recorded indication, and 40% had no medication review in the past year, underscoring the gap between policy and practice.2
What GORD might be hiding GORD is one of the most common reasons for GI referral, yet the diagnostic pathway remains crude and inefficient. Patients present
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with reflux symptoms, they are referred for endoscopy to rule out cancer, and if results are normal, they’re sent back to primary care for long-term PPIs. Two years later, the cycle repeats. For hospital managers, this creates a bottleneck: high volumes of low-risk patients strain endoscopy capacity. It is a pathway that screens for cancer — which most won’t have — but misses everything else. The West Suffolk capsule sponge pilot offers a glimpse of what’s possible. Instead of defaulting to endoscopy, patients with persistent heartburn were offered a non-endoscopic cell collection test in the community. It was faster, cheaper, and more acceptable to patients (and it identified Barrett’s oesophagus in nearly 20% of those tested). For the majority, it ruled out serious pathology and avoided unnecessary procedures.6,7 Breaking the cycle means rethinking reflux diagnostics. Capsule sponge triage can be followed by targeted diagnostics like pH monitoring, manometry, hydrogen/methane breath test or Alimetry. These tests can confirm
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