Abstract Background Ulcerative colitis (UC) requires proactive, structured monitoring to prevent relapse, avoid steroid overuse, and reduce emergency care utilisation. However, in primary care settings—particularly rural practices—monitoring is often inconsistent. We undertook a quality-improvement review to improve disease visibility, embed faecal calprotectin (FCP) monitoring, and develop a treat-to-target (T2T) maintenance and flare pathway aligned with best practice. Methods To evaluate UC care within a rural primary care population; to enhance patient reviews through systematic FCP monitoring; and to design a pragmatic T2T maintenance pathway and evidence-based flare pathway suitable for implementation in general practice. A mixed-methods approach combined retrospective electronic record review with multidisciplinary (MDT) thematic analysis. Data included demographics, diagnostic timelines, FCP test utilisation, relapse documentation, steroid courses, multimorbidity profiles, and gastroenterology correspondence. MDT discussion explored confidence in flare management, use of biomarkers, and opportunities to embed T2T principles. Findings were benchmarked against NICE NG130, BSG guidance, and IBD-UK 2023 standards. Results The review revealed substantial variation in FCP use, with many patients lacking recent objective assessment of disease activity. Coding inconsistencies contributed to poor visibility of patients at risk of relapse. High comorbidity burden—including cardiometabolic and hepatic conditions—underscored the need for structured monitoring. Enhanced record searches and MDT review enabled the practice to introduce systematic FCP testing as part of routine annual and interim reviews. This facilitated stratification of patients into a newly developed T2T maintenance pathway focusing on biomarker-guided monitoring, optimisation of 5-ASA, and reduction of unnecessary steroids. A complementary flare pathway was produced, incorporating early FCP testing, rapid GP review, safety-netting, and defined thresholds for urgent gastroenterology escalation. Conclusion The project demonstrates that primary care can deliver robust UC monitoring when supported by digital tools, standardised templates, and clear clinical pathways. Embedding FCP testing within routine reviews enhances disease control and supports T2T principles, enabling timely identification of deterioration and reducing unwarranted variation. A structured flare pathway further strengthens continuity of care and promotes earlier, evidence-based intervention. Ongoing work will integrate patient-reported outcomes and refine pathway use across the wider locality. References: 1. National Institute for Health and Care Excellence (NICE). Ulcerative colitis: management. NICE Guideline NG130. London: NICE; 2019 (updated 2022). 2. British Society of Gastroenterology (BSG). Lamb CA, Kennedy NA, Raine T, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019;68(Suppl 3):s1–s106. 3. Turner D, Ricciuto A, Lewis A, et al. STRIDE-II: An update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) initiative of the IOIBD: Determining therapeutic goals for treat-to-target strategies in IBD. J Crohns Colitis. 2021;15(10):1603–1612. 4. Van Rheenen PF, Van de Vijver E, Fidler V. Faecal calprotectin for screening of patients with suspected inflammatory bowel disease in primary care: A meta-analysis. BMJ. 2010;341:c3369. Conflict of interest: Ellis, Victoria: Non-promotional grant from Ferring Deaney, Carl: Non-promotional grant from Ferring
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