HSC(6)-14-23 Papur 4 / Paper 4

Health and Social Care Committee Endoscopy services: follow up inquiry

Written Evidence Submission:

Hayley Heard – Programme Lead, National Endoscopy Programme

December 2022

Background

1. The National Endoscopy Action Plan (which can be found on the Welsh Government

website at https://gov.wales/sites/default/files/publications/2019-10/national- endoscopy-programme-action-plan-2019-2023.pdf) was published in October 2019. The action plan clearly sets out the original, pre pandemic NEP work plan for 2019- 2023.

2. The action plan’s immediate phase actions were completed on time and a diagnostic

workshop was held on 6^th March 2020, presenting its findings and recommendations for delivery of the overall aims.

The impact COVID-19 has had on delivery of endoscopy services and the implementation of

the national endoscopy action plan, and the implications of this for patient outcomes and survival rates.

In March 2020 Welsh Government announced the suspension of all non-urgent

outpatient appointments, surgical admissions, and diagnostic procedures, due to high risk of transmission of the Covid-19 virus and the prioritisation of Personal Protective Equipment (PPE). This significantly impacted all endoscopy services across Wales, and the UK.

The British Society of Gastroenterology (BSG) swiftly issued further advice

recommending all non-emergency endoscopy procedures should be stopped.

The Bowel Screening Programme also suspended its service, until July 2020.

Between March and June 2020 staff within the endoscopy teams and the NEP were

recruited to support the emergency and critical care management of Covid-19 patients.

The National Demand and Capacity (D&C) modelling tool developed by the NEP as

part of the action plan, showed in April 2020 there was only 6% of the total endoscopy activity delivered compared to Feb 2020 (fall of 94%).

8. In light of the significant challenges faced within endoscopy services across Wales,

understanding that delivery of the original action plan would be affected by the pandemic; the NEP rapidly developed a recovery plan that was signed off by the NEP Board and presented to the Welsh Government in April 2020.

9. The NEP and BSG produced recovery guidance in May 2020 setting out 3 phases to

recovery. It also sourced and produced a plethora of information and guidance to support recovery such as air flow guidance in endoscopy units.

10. In October 2020 the NEP submitted a refreshed Action Plan (which can be found on

the Welsh Government website at https://gov.wales/sites/default/files/publications/2020-12/national-endoscopy- programme-revised-action-plan-october-2020_0.pdf) which set out the original actions planned for the immediate, stabilisation and sustainability phases of the programme; achievements to date and revised deadlines for delivery of remaining actions; along with the additional actions necessary to support Health Boards recover from the pandemic.

11. The NEP Board agreed the extension of the programme to December 2023 in order to

continue progression of the action plan.

The priority given to endoscopy services in the Welsh Government’s programme for

transforming and modernising planned care, including who is responsible for delivering improvements through the reconfiguration of services and new models of care (including additional endoscopy theatres, diagnostic centres and regional units), and how endoscopy services will feature in the new cancer action plan (expected to be published autumn 2022).

12. The Covid-19 pandemic exacerbated many pre-existing challenges within endoscopy

services across Wales, and Health Boards are under increased pressure to manage the backlog of patients awaiting an endoscopy procedure, as well as build a sustainable endoscopy service for the future.

13. In October 2021 the Welsh Government Minister for Health and Social Care approved

the NEP recovery plan and the deputy CEO for NHS Wales and Deputy Chief Medical Officer for Wales wrote to Health Board CEO’s setting out the overall approach to include:

II.

Maximising outputs from existing units

Continuing health board short term additional activity i.e., insourcing, waiting list initiatives

Considering business cases for permanent local increases in capacity Procurement of managed service contracts to develop regional units

III.

IV.

14. The NEP published action plan & additional components of the recovery plan have

been developed into an integrated work plan.

15. In October 2021 Regional Operational Groups supported by the NEP were established

to develop plans to deliver the NEP recovery plan, in line with the Welsh Government Minister for Health and Social Care’s approach.

16. The NEP established within their core team a regional lead who links in with HBs on a

regular basis to provide support, information sharing and continuity.

Issues relating to recovering and improving waiting time performance, including: reducing

waiting times for diagnostic tests and imaging to eight weeks by spring 2024 and support for people waiting for tests and follow up appointments; the active waiting list size for all current inpatient and day-case patients waiting for endoscopic procedures (by modality); the extent to which elective capacity is impacted by emergency activity, and whether there is sufficient data to understand the impact of emergency cases; whether high risk patients requiring ongoing surveillance endoscopic procedures are included in current demand and capacity planning models; the scope for upscaling lessons learned from previous waiting list initiatives such as insourcing, outsourcing or mobile units; and what the current demand and capacity modelling tells us about when a sustainable position can realistically be achieved.

17. The recovery of the pre-pandemic endoscopy waiting list position was already

challenged for NHS Wales, with work carried out prior to 2020 identifying a shortfall in capacity to deliver against demand levels (based on no improvement in productivity) of between 18 and 25 lists per week throughout Wales.

18. April 2020 saw a drop-in overall endoscopy activity of 94% in comparison to February

of the same year due to the effect of COVID-19 and the resulting closure and redistribution of key health care services having a dramatic effect on endoscopy capacity. Whilst this dramatic change in activity would result in an increase in the total size of the waiting list, this was somewhat mitigated by a corresponding fall in the number of endoscopy requests, with a fall of 78% observed in the same month when compared to February 2020.

19. Both the numbers of activity and of requests received would continue to recover

toward pre-COVID levels as the year progressed. Activity would climb from 6% of pre- COVID levels in April 2020 to 50% by December 2020, and request levels would rise from 22% of pre-COVID levels in April 2020 to 65% by December 2020.

20. Whilst both figures would continue to rise, the disparity between requests (adding

patients to the waiting list) and activity (removing patients from the list) would mean that the waiting list would continue to grow in size. From a total of 10,305 waiting in February 2020¹ to 18830 waiting in December 2020.

¹ (Waiting list numbers presented here are for colonoscopy, gastroscopy, or flexi sigmoidoscopy only, excluding screening and surveillance)

Data sources – National Endoscopy Programme for activity and request numbers,

Diagnostic and Therapies Dataset for Waiting List numbers.

21. Notably as the time spent on the waiting list continued to grow the number of

patients waiting for more than 8 weeks would rise even faster – with 1,566 waiting for more than 8 weeks in February 2020 rising to 12,277 by December 2020. This pattern would continue through to December 2021, with slowly recovering activity, up to 70% of pre-COVID levels by that time, and requests which were up to 82%. The waiting list would rise further to a total of 23,711 with 15,911 waiting for more than 8 weeks.

22. At the time of writing, this growth in the waiting list has largely been halted, with

22,604 total waiting at the end of September 2022 and 14,522 of these waiting for more than 8 weeks.

23. The total number of patients waiting for endoscopy has risen by more than 100%

between February 2020 and September 2022. (10305 in Feb 2020 to 22604 in Sep 2020). The proportion of patients waiting for 8 weeks or more has risen from 15% of total waits in Feb 2020 to 64% in September 2022 (from 1566 in Feb 2020 to 14522 in Sep 2022), a rise of over 800%. The proportion of patients waiting for 14 weeks or more has risen from 9% of total waits in Feb 2020 to 52% in September 2022 (from 906 in Feb 2020 to 11708 in Sep 2022), a rise of over 1100%. The proportion of patients waiting for 24 weeks or more has risen from 3% of total waits in Feb 2020 to 37% in September 2022 (from 327 in Feb 2020 to 8438 in Sep 2022), a rise of over

2400%.

24. Surveillance endoscopic procedures are included within current demand and capacity

planning models.

25. The NEP developed guidance, published in early 2021, to support HBs in their risk

stratification of all surveillance patients, in light of waiting time challenges post- pandemic. This followed on from the 2019 guidance on the implementation of surveillance guidelines for post-polypectomy and post-colorectal cancer resection to ensure the appropriateness of patients on surveillance waiting lists across Wales.

26. In order to support HBs with waiting list management the NEP in partnership with the

Bevan Commission has established a national pilot of Colon Capsule Endoscopy and will support the dissemination of evaluation findings of pilots of Trans-nasal Endoscopy (TNE) and Cytosponge.

27. Many of the regional solutions provided and the data submitted now indicates an

improving position regarding planned increased capacity over the next 12 months. This capacity, however, appears to be predicated against higher risk / non-sustainable solutions such as insourcing solutions, outsourcing solutions, temporary funding,

Waiting List Initiatives (funded by Welsh Government) and short-term additionality

reliance on staff “good will”. In the shorter term the current demand and capacity modelling tells us that HBs/Regions can largely absorb the current demand levels and overall, can consume the additional waiting cohort with this additional planned capacity. However, the modelling shows clearly that this will be only the case for the next 12 months. The model predicts increasing demand levels over the years ahead,

and this coupled with the inability to confirm additional funding into 23/24 and 24/25

and later - would result in a rapid regrowth in waiting lists in those later years. The model also assumes that these capacity solutions can be operational soon. This

model assumption obviously does not take into consideration the ‘real-world’ operational risks around delivery of this capacity and should therefore be considered higher risk.

What barriers there are to achieving accreditation from the Joint Advisory Group on GI

Endoscopy, including whether health boards are investing sufficient resource in developing the facilities and infrastructure for endoscopy services, decontamination services, and the progress that has been made in expanding the endoscopy workforce.

Joint Advisory Group on GI Endoscopy (JAG) Accreditation

28. Each Endoscopy Services’ state of readiness and potential to participate in a JAG

assessment was examined in late 2019 by the NEP, via a series of service visits and engagement with service teams. Following this exercise, formal pre-JAG visits were undertaken by external JAG assessors, to gain an up to date understanding of the state of readiness of endoscopy services to participate in a JAG assessment, and the barriers affecting local progress towards accreditation. Following these visits, a series of pre-assessment reports were developed, clearly defining the actions and trajectories for achievement of JAG accreditation and an accurate description of limiting factors for each endoscopy unit across Wales.

29. In 2021, the NEP identified eight units recognised as being in a strong position to

focus and apply for an assessment for JAG accreditation within 6-12 months.

30. Currently only one of the aforementioned units believe they are in a position to apply

for assessment for JAG accreditation by March 2023; with service and managerial capacity pressures cited as one of the main reasons not to pursue accreditation. As such, no tangible progress made towards one of the Programme’s key aims of achieving JAG accreditation of endoscopy units.

31. The NEP recognises the additional pressures faced by endoscopy services as a

consequence of the COVID-19 pandemic, and the impact this is having on the capability of operational teams to prepare for and be in a position to apply for and achieve JAG accreditation.

32. To support endoscopy services in their plans to achieve JAG accreditation, the

National Endoscopy Programme has established a number of support mechanisms, through providing additional capacity and expertise. These include:

The development of a SharePoint site to share JAG materials to aid services in

pulling together evidence to demonstrate their compliance against the JAG standards.

Monthly drop-in sessions (chaired by a Lead JAG Assessor) to offer guidance and support to services on the JAG standards.

Training sessions to educate endoscopy teams on the steps required to prepare for accreditation.

Targeted meetings to raise awareness with Endoscopy Executive Leads.

Annual decontamination audits to review the quality and safety of decontamination facilities across Wales.

Quarterly meetings with the central JAG team, including the JAG Chairman, JAG Accreditation Managers and Lead JAG Assessors.

33. In recognition of the impacts of the pandemic, JAG are currently excluding their

mandatory minimum waits from the accreditation process (recognising that units will be many months away from meeting this). This pragmatic and flexible approach presents endoscopy units in Wales with an opportunity to achieve accreditation, despite a historic inability to meet ministerial waiting time targets. It is the view of the programme that this revised approach from JAG presents Wales with the best chance of getting the majority of units JAG accredited.

34. Whilst some progress has been made to increase compliance against the JAG

standards across a number of units in Wales, no service has gained JAG accreditation since this initial assessment in 2020. The list below summaries the outstanding challenges facing each endoscopy service, hindering progress made towards achieving JAG accreditation. These include:

Increased pressure on the leadership teams within services – with no additional

support for clinical (Medical and Nursing) and managerial leads to deliver and complete the work required for accreditation, despite recommendations for services to invest in quality manager roles.

A lack of understanding of endoscopy services at senior management level. Poor facilities & infrastructure which require major capital investment – this includes decontamination facilities.

Loss of particular focus on key JAG standards e.g., quality, safety (audits) and training.

No coordinated approach to achieving accreditation within Health Boards. Poor knowledge of capacity planning for endoscopy service delivery, including workforce requirements.

Inadequate systems to support productivity measurements, reports, and improvements.

Short term solutions to address capacity issues and waiting list backlogs. Health Boards not being directed to submit applications for accreditation and accreditation seeming to be optional

Expanding the Endoscopy Workforce

35. In May 2022, the NEP held a National Workforce Planning workshop, to engage a

select number of the endoscopy community, to agree on a vision for the endoscopy workforce of Wales and begin to develop a plan for implementation. Following this workshop and given the challenges experienced by many services in the access and availability of endoscopy workforce data, a series of workforce planning visits were undertaken with all HBs to support them with their development of local endoscopy workforce plans.

36. In order to appropriately engage the endoscopy workforce across Wales, the NEP has

developed a Workforce Stakeholder Engagement Taskforce supported by a dedicated Endoscopy Community Teams channel.

37. Through consultation with Clinical Endoscopists and key stakeholders within the

endoscopy clinical community and wider, the NEP has developed a series of Clinical Endoscopist national role profiles. These have been developed in conjunction with Trade Union colleagues, job matched by the All-Wales Job Evaluation Unit and recommended as best practice guidance to all HBs within Wales.

38. The NEP has worked closely with an external design agency and the endoscopy

community in Wales to develop a bilingual National Attraction Campaign for use by all Health Boards to support endoscopy recruitment.

39. The NEP has worked with Health Boards to introduce new and advanced roles within

their structures to ensure an improved career pathway – these include Clinical Endoscopists, Clinical Nurse Educators to focus ion training and development (nursing) roles, JAG Nursing Leads and Co-Ordinator roles to support JAG accreditation of units. These have helped to define career pathways for professions and improved traditionally ‘flat’ nursing and administration structures to support with the recruitment and retention of the endoscopy workforce in Wales.

40. The NEP has developed a Band 4 Assistant Practitioner qualification in Endoscopy,

with a task & finish group established for assessment and resource development to aid training implementation.

41. The NEP has recruited to three Clinical Endoscopist cohorts, with delivery of training

through HEIW and Swansea University and the first cohort of Physician's Associates training in colonoscopy has commenced.

42. An All-Wales Education and Training Management Group (ETMG), chaired by the

Health Education Improvement Wales (HEIW) Postgraduate Dean has been established with four clinical leads appointed to oversee all-Wales endoscopy education and training approaches – the group, via engagement with the endoscopy workforce has identified ten training pathways as key areas of focus.

A Training Academy proposal paper has been formally submitted to Health

Education Improvement Wales (HEIW) Executive

All-Wales prescribing guidelines have been agreed and formalised for distribution. The first all-Wales undergraduate nursing endoscopy training session has been delivered

Bowel Cancer Upskilling & Potential Screener pilot workshop has been completed. All Wales training data and estimates of training capacity requirements has been collated from various information sources to provide us with an overview of the training picture.

The current position for optimising the bowel cancer screening programme (i.e., for

increasing Faecal-Immunochemical Testing (FIT) sensitivity and age testing) and how this compares to other parts of the UK. The experiences of younger people and those most at risk of developing bowel cancer (i.e., those living with Lynch syndrome) and efforts to diagnose more patients at an early stage.

43. Please refer to the Bowel Cancer Screening programme for response to the above

questions

Primary care access across different health boards to FIT for patients who do not meet the

criteria for a suspected cancer pathway referral and how it is being used to help services prioritise patients and stratify referrals by risk (outpatient transformation).

44. The NEP has focused on assessing options to support Health Boards (HBs) to increase

their diagnostic capacity within the LGI pathway, especially while having to address the increasing backlogs of patients waiting for procedures. These efforts have been targeted at implementing those interventions likely to have the greatest impact and scale, progressing systematically in descending order of likely impact, and capacity creation within the service. With this strategy we have thus far supported implementation of:

the surveillance validation of colonoscopy according to updated BSG guidelines

which resulted in 50-70% of surveillance capacity being freed up in those HBs where validation has been implemented to a significant extent

embedding of the Faecal Immunochemical test (FIT) for routine referral streams (NICE DG30) in HBs across Wales and implemented a pilot for USC referrals in Cardiff and Vale UHB.

The piloting of Colon Capsule Endoscopy

45. In March 2021, ahead of the planned action plan timeframe the NEP produced an

evidence-based and externally peer reviewed FIT National Framework ahead of time in order to guide and support Health Boards during the Pandemic and provide a common approach to the implementation in primary and secondary care.

46. The NEP shared best practice and learning at a national symptomatic FIT learning

event in April 2022.

47. Six HBs have now fully implemented use of symptomatic FIT in primary care within

the low risk (DG30) population while the last HB will have a pathway in place by March 2023.

48. HBs to date report challenges with administrative and informatics support in FIT

implementation that is proving to be a barrier to improved, more rapid implementation, and to the tracking of referrals and implementation of safety netting processes.