Wind of change: what can we learn from the National Endoscopy Database?

Introduction

On 3 February 1960, Harold Macmillan the British Prime Minister addressed the South African parliament in his ‘The wind of change speech’ signalling the growth of national consciousness being a political fact and the deep conviction about political destinies of free men and the odious aspects of current policies.¹ Thirty-one years later, the Apartheid laws were repealed.

While we cannot equate the enormity of this geopolitical change with endoscopy, our ‘wind of change’ is blowing, providing opportunity, to describe, design and deliver success using the intelligence extracted from the National Endoscopy Database (NED) analysis² and aligning this with the diagnostic strategy. One thing is clear, we need change.

Endoscopy is the gateway to most gastrointestinal (GI) cancer diagnoses and an essential tool in managing long-term GI pathologies, many of which carry risk for the development of future GI malignancy. Endoscopy is both a diagnostic and a powerful therapeutic tool allowing minimally invasive complex endotherapies by highly skilled operators.

The analysis of the NED by Beaton et al provides a broad visual canvas on the state of endoscopy in the UK.² It is comprehensive and considered 1 639 640 procedures from 407 sites and 4990 endoscopists. The analysis considered sites by UK nation with England categorised using the NHSEI (NHS England and NHS Improvement) seven regional designations. Workforce was viewed through the lens of gender, specialty and trainee status. Selecting the time frame of March 2019–February 2020 eliminated the exogenous impact of the pandemic.

The NED records activity and not demand, however, the current backlog for diagnostics in England is significant with 1 568 964 waiting for the 15 tests monitored by NHSE (NHS England diagnostics waiting times and activity (DM01)).³ Endoscopy accounts for 182 640 of this backlog with 34.8% of patients waiting more than 6 weeks (NHSE data). Large regional and system variation in performance is apparent. The Integrated Care Systems backlog for endoscopy ranges from nearly 6000 patients waiting on an endoscopy with 66% waiting greater than 6 weeks to as much as 51 weeks. The reported DM01 measurement does not take into account planned, surveillance or inpatient procedures, so the true scale of demand is still greater. This provides a palpable sense of scale and challenge.

Factors influencing current backlog

The background we are operating in cannot go unnoticed and gives substance to the challenge. We have emerged from a pandemic during which activity was severely curtailed to manage the infection risk to patients and operators. This supported staff redeployment to ensure business continuity in acute hospitals, however, the net impact created a dam wall to flow swelling the reservoir of backlog.

The NHS long-term plan⁴ rightly has a clear focus on expanding bowel cancer screening through age extension. It sets the ambition that by 2028 the proportion of cancers diagnosed at stage 1 or 2 will rise from half of all cancers to three-fourths of all cancers.

In terms of recovery and reset in England, there is a requirement that 95% of all diagnostics will be delivered within 6 weeks by March 2025 along with the elimination of all electives waits greater than 1 year. In England, the new 28-day Faster Diagnostic Standard for cancer has set at target of 75% attainment by March 2024, and it is the expectation that the 62-day standard will match the prepandemic performance by March 2023.

The diagnostics recovery and renewal strategy⁵ provides a clear direction of travel for the growth of diagnostic capacity to deliver these endpoints. The Community Diagnostic Centres (CDC) programme is the vehicle of deliver, along with an ambition to level up endoscopy provision to 3.5 rooms per 100 000 population over the age of 50. The net effect of this additionality will be an increase capacity; however, the workforce implications and challenge are significant. This will require training at scale, not only for endoscopists but all aspects of the service. This work has been initiated in England through the creation of the endoscopy academies programme commensurate with the NHSE regions. This will no doubt accelerate training, however it still requires the current workforce to deliver the training and deal with the backlog and ongoing demand.

In the NED analysis, much is made of the unused weekend capacity. Weekend days (which make up 28.6% of a 7-day week) accounted for 16% of procedures performed. Weekend activity in the current climate is largely delivered in the form of waiting list initiatives or variants of this. In the main, the weekend workforce is the exact same as the weekday workforce. Weekends provide flexibility and choice for staff to provide services freed from their fixed weekday commitments. This coupled with the deeply concerning fact in the NED analysis that half of endoscopists (gastroscopies 52% and colonoscopies 48%) did not meet minimum annual procedural numbers as recommended by British Society of Gastroenterology (BSG) quality standards.^{6 7}

If one applies some simple arithmetic to the backlog described, we will require approximately an additional 718 list per week to deal with backlog and manage current demand. The BSG 2018 census identifies 1570 consultant gastroenterologists of which 153 were pure hepatologists. If we remove this group (we appreciate the extensive contribution this group makes to endoscopy) and take into account that 34% of respondents have no general internal medical commitment, this crudely means we have 936 gastroenterologists who have broad clinical responsibilities outside of endoscopy and gastroenterology. If gastroenterologists were focused on using their expertise and providing more endoscopy, something most would welcome (authors view), then we have around 900 additional lists available per week if this group were to perform one more additional list. This provides an immediate and sustainable solution bridging the way to training greater numbers and providing a flexible workforce to support CDCs.

The current clinical endoscopists (non-medical endoscopists) strongly demonstrate their contribution in the NED analysis, with a workforce comprising 12% of endoscopists providing 23% of activity (2). Interesting data from one of the NHSE regions demonstrated an inverse relationship between the numbers of clinical endoscopists, size of backlog and the proportion of patients waiting greater than 6 weeks for a procedure (see figure 1).

Figure 1.

Relationship of numbers of clinical endoscopists and the trusts percentage of 6 weeks plus waiters. CE, clinical endoscopists (usually from a nursing background; NHS, National Health Service, SW, south west.

Clinical effectiveness can be described as the right person doing the right procedure at the right time. We appreciate the need to balance priorities and recognise the pressure on hospital front doors, however, outsourcing this function to a specialty that can potentially unlock the endoscopy backlog and provide a bridge to sustainable solutions feels like a modest investment with a high rate of return and limited risk.

The analysis of the NED database has lifted the lid on endoscopy practice. Positive national investment to improve capacity is in flight, however, the workforce is a key constraint, but even more shocking is the number of operators not delivering minimum numbers to meet agreed published quality standards. The reasons for this are varied and complex, but can be addressed and the efficiency of the workforce optimised.

The winds of change are blowing, and we need to embrace this change and take bold steps to make it happen.

Obstacles

The germane analysis above is hard to disagree with. There are many steps suggested we (as gastroenterologists) could and should take that would improve utilisation of endoscopy resources to bridge over the pressing shortfall in endoscopy provision. Yet there are several obstructing factors which may make realisation of this plan unachievable.

There is a crisis or recruitment and retention for healthcare professionals, this predated the COVID-19 pandemic, though the ongoing challenges of the pandemic has exacerbated this crisis significantly with a real concern of the effect of the pandemic will have in terms of moral distress.

The Royal College of Physicians (RCP) census has shown that 52% of advertised consultant physician posts in England and Wales went unfilled last year—the highest number of unfilled posts on record. Up from 43% before the pandemic and 48% in 2020, this is the highest rate since records began in 2008. The census data also shows 44% of current consultant physicians will reach retirement age in the next 10 years (assuming an average retirement age of 62–63). The RCP has long called for a doubling of medical student numbers to try and address the shortfall of consultants in the future.⁸

The BSG 2021 workforce report has shown that 48% of advertised consultant gastroenterology and hepatology posts in 2020 were unfilled, and average intended retirement age was reported as 61.5 years with 51% of consultants reaching this age over the next decade. Gastroenterology is the major physician specialty at highest risk of burn-out (moral distress) with lower (worse) mean mental well-being scores.⁹ In a recent Midlands wide endoscopy workforce questionnaire, 40% of all medical/surgical endoscopists were planning to retire in the next 5 years and 6% of endoscopists were working on a retire and return basis.

Ultimately, the direct and indirect implication is that there are not enough gastroenterologists to undertake more endoscopy lists and there are not enough physician colleagues for gastroenterologists to drop general medical responsibilities and other hospital commitments to concentrate on endoscopy provision.

Finally, there is trouble ahead as the cost of living crisis bites, ongoing subinflationary annual salary increments have severely impacted on consultant’s real term pay—reducing by a third in the last 13 years. This impact is similar for all healthcare professionals, extending to trainees and the clinical endoscopy workforce. There are risks of disruptive industrial action in the future. In addition, current pension taxation rules are having a constraining effect, limiting clinicians taking extra clinical sessions, and resulting in consultants close to retirement age having to retire and return on a reduced job plan.

The climate crisis must not go unnoticed. There is a legal requirement to address and reduce carbon footprints. Endoscopy has a heavy footprint in terms of travel of patients, the decontamination of endoscopes and the high single use disposable plastic materials and the packaging they are stored in. The green endoscopy revolution is coming and is at loggerheads with the calls for increasing number of endoscopy procedures.

Alternatives and innovation will be key—such as cytosponge, and increasing use of triage tools to potentially reduce the number of endoscopy procedures—such as faecal immunochemical testing (FIT). While the yield of bowel cancer screening colonoscopy is worthwhile (~40%–50% with adenomas, ~6%–10% with colorectal cancer), the yield of 2-week wait/urgent suspected cancer endoscopy remains below 10%.

The wind of change is blowing, and the NED analysis has provided a route map for for endoscopy services to navigate the seas that represent the shortfall of current provision. However, the obstacles highlighted suggests the seas may well be treacherous, and the journey will be a difficult one.

Ethics statements

Patient consent for publication

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