|
Cynulliad Cenedlaethol Cymru |
National Assembly for Wales |
|
Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon |
Health, Social Care and Sport Committee |
|
Ymchwiliad i wasanaethau Endosgopi |
Inquiry into Endoscopy Services |
|
HSCS(5) E11 |
|
|
Ymateb gan Conffederasiwn GIG Cymru |
Evidence from Welsh NHS Confederation |
1. The Welsh NHS Confederation welcomesthe opportunity to respond to the Health,Social Care and Sport Committee’s inquiry into endoscopy services in Wales. The Welsh NHS Confederation represents the seven Local Health Boards, the three NHS Trusts in Wales and Health Education and Improvement Wales (HEIW). We support our members to improve health and wellbeing by working with them to deliver high standards of care for patientsand best valuefor taxpayers’ money. We act as a driving force for positivechange through strong representation and our policy, influencing and engagement work.
2. Over a number of years, NHS Wales has been working to bring endoscopy demand and capacity into balance to enable delivery of the eight-week diagnostic target and endoscopy unit accreditation. Clinical Directors and management leads have been collaborating through the national Endoscopy Implementation Group (EIG) and significant progress has been achieved.Eight-week breaches have declined and additional units have achieved accreditation.
3. In this financial year, NHS leaders have agreed to establish a national programme for endoscopy services, led by a reformed EIG, to provide an additional and sustained focus on the service in the next period and to develop a plan which will reduce the screening threshold and age range to optimal levels by 2023. Immediate priorities for the programme include: completing demand and capacity modelling; developing a standardised pathway to drive maximum efficiency and productivity; and ensuring workforce plans and Integrated Medium Term Plans (IMTPs) for 2019 and beyond take account of uplift in capacity that will be required.
4. This paper will address the five areas of focus identified in the Terms of Reference of the inquiry.
5. Our members welcomethe introduction of the FIT test from January 2019 into the bowel screening programme as part of a strong evidence-based changethat has the potential to improve the uptake of screening. This is due in large part to the new test that requires just one (instead of three) samples,as well as an improveddetection rate for bowel cancer and advanced pre-cancerous polyps in the bowel.
6. Health Boards and Bowel Screening Wales are working together to review their capacity to deliver the FIT and have assessedthe anticipated impactof increased uptakeof the test as a result of three keychanges:
a. Changes in the administration of the test;
b. Changes to the sensitivity of the test and the level at which an individual would be invited for a diagnostic procedure; and
c. The lowering of the age of those to whom a test will be sent.
7. In addition, bowel screening is currently offered to men and women aged 60 to 74 using a Guaiac Faecal Occult Blood test and colonoscopy, if necessary. Extending screening for men and women aged 50 to 74 by the year 2023 is expected to result in increased demand for diagnosis and treatment services. Currently for patients categorised as Urgent Suspected Cancer (USC), Health Boards are either meeting, or close to meeting, the requirement to offer a procedure date within two weeks of the screening assessment appointment. The challenge will be maintaining that level of performance in the face of additional demand.
8. As mentioned, endoscopy services across Wales face extremely testing workforce challenges, which are exacerbated by an average increase in demand for services of 8- 10% per annum. As a result, our members have had to work under extreme workforce and resource pressures to deliver the level of service that is required.
9. It is for these reasons that the planned threshold for introduction of the FIT test of 150 (micrograms/gram of stool – unitssame throughout) has been set, so that NHS Walescan balance the drive for improving outcomes from bowel cancer through earlier and increased diagnosis with the constraints of current endoscopycapacity. Due to these very real capacity constraints, it is necessary to have a phased approach and there is a commitment from NHS leaders, working with Welsh Government, to reducing the screening threshold and age range to optimal levels by 2023.
10. The next step is to identify the resources that will be required to meet the anticipated future demand and local project teams are being developed in some areas to implement and manage changes in practice. These teams will comprise local GP cluster leads, a specialistscreening practitioner lead and a service managerfor endoscopy. HealthBoards are also starting to work with primary care colleagues to support the early intervention agenda, for example through possible FIT testing by general practitioners.
11. In recent months, Health Boards have sought to manage the increased levels of demand for treatment by utilising sites outside of their operational boundaries. This practice has since come to an end and some Health Boards have developed plans to improve sustainable capacity. While challenges persist, there are a several streams of work ongoing that are seeking to maximise efficiency, productivity and list utilisation. Health Boards are also reporting increased numbers of nurse endoscopists which have been progressed as a contingency to managing the increased demand for routine endoscopy. Having nurse endoscopists in post to deal with routine endoscopyprocedures means that senior clinicians have more time to undertake the more complex procedures.
12. We would emphasise however that despite these measures, the fact that nurse endoscopists also deliver a range of other clinical commitments as part of their job plan means that Health Boards continue to experience significant challenges to delivering the level of service that is required. Our members feel that amending these job plans, as well as an increase in the recruitment of colonoscopists and nurse endoscopists, is urgently required to meet currentlevels of demand.Our members also emphasise the need for an IT system that integrates the bowel screening software with units of endoscopy activity so that the data can be captured and compared across platforms.
13. Generally, Health Boards have a good understanding within the Gastroenterology, Hepatology and Endoscopy Directorates about the workforce and infrastructure requirements that are necessary to deliver the plans for roll out of FIT under the Bowel Screening Programme. There is also a generally good understanding of the annual increase in demand on the wider symptomatic service, current backlogs, surveillance waits and proposed roll out of FIT that may be informedby planned pilotsin primary care.
14. In addition to future workforce planning within endoscopy and establishing the number of required professionals, Health Boards also need greatercapacity in terms of increasing physical space and equipment to cope with the anticipated additional demand. Where necessary, this needs to underpin workforceplans with significant input from strategyand estate teams.
15. Recent plans for improvement in endoscopy serviceshave focused on meeting immediate targets rather than building sustainability and resilience into the system. Our members will continueto work with the Welsh Government to ensure that the infrastructure needs of the service are built into IMTPs and national investment plans.
16. The introduction of FIT testing as part of a primary care/secondary care diagnostic pathway in symptomatic patients has some evidence to support its use, particularly for “low risk” patients(e.g. NICE Diagnostic Guidance 30). Despitethis, the evidencebase for the effectiveness of FIT testing as part of a primary care/secondary care diagnostic pathway in symptomatic patients is not as robust as it could be.
17. It is for this reason that Health Boards have been working collaboratively to outline what the baseline data collection and pathway measuresneed to be to pilot a study of this type. It is hoped that research of this kind will strengthen the evidence base for such an intervention so that it can be used in bowel cancer screening procedures in future. The Wales Cancer Network has been a key partner in this work. Health Boards have also engaged in detailed discussions with NHS organisations in Scotland (where a pilot has already taken place) to learn from their experiences, and with organisations in NHS England such as the FIT pioneers’ group.
18. It is hoped that through continued engagement with the groups involved in the all-Wales initiative, such as Health Technology Wales and the Welsh Association for Gastroenterology and Endoscopy (WAGE), at least one Welsh Health Board will be well- placed to pilot a systematic and evidence-based roll out of FIT testing for symptomatic patientsin 2019. The hope is that havingthe pilot in place in one HealthBoard will enable other Health Boards to structure and implement their own services to integrate this into the symptomatic diagnostic pathway.
19. Our members recognise the importance of increasing uptake of the bowel screening programme and a number of approaches are currently in development to address this challenge. Examples of such interventions include the dissemination of consistent key messages, pre-invitation lettersand primary care pilots with non-responder data. Further examples of ongoing work in this area include analysis of Cancer Research UK’s “Be Clear on Cancer” campaign; the development of further pilots in primary care; collaborative projects with charity organisations to develop community engagement workers; and a review of letters and leaflets using behavioural insight techniques that aim to develop culturally and literacy sensitive material.
20. Our members welcome the introduction of the FIT test into the bowel screening programme and are taking a strategic approach to demand and capacity planning to prepare for its introduction. Health Boards are working closely with Bowel Screening Wales, are committedto the National Programme for Endoscopy servicesand are working closely with colleagues and partners across Wales and in other UK countries to drive improvements and achieve the efficiency savings that are required.