The nation’s endoscopy service faces a multitude of drivers behind the specialty’s increasing strain, including unnecessary referrals from primary to secondary care, increasingly-complex procedures, and high staff vacancy rates.
And effective triage and technological innovation between primary and secondary care is vital to support the recovery of the service, with the NHS as a whole facing a backlog of three million people waiting more than 18 weeks for treatment.
Endoscopy services play a significant role in diagnosing and treating various cancers and these are time-sensitive diseases that patients cannot afford to be waiting for diagnosis and treatment.
Containing patient flow from primary care, while providing technical innovation, is essential to be able to retain clinical capacity, deal with the growing pressure, and make progress on reducing the rising waiting lists.
A multitude of drivers
The pressures that the endoscopy service is facing are complex, with many being felt across the entire healthcare system.
A record number of staff vacancies were recorded at the end of 2022, with over 130,000 posts unfilled.
And this has only been exacerbated by the industrial action taken from December 2022, with further strike action planned by junior doctors.
Effective triage and technological innovation between primary and secondary care is vital to support the recovery of the service
The full effects on the existing workforces are yet to be seen as a result of these strikes.
More specifically to the endoscopy service itself, there are a number of strains contributing to the growing waiting list backlogs, including:
- A lack of space – endoscopy procedures require a large chunk of floorspace to perform – which is at a premium in any busy hospital A lack of inpatient beds can also impact on getting patients in for more-advanced procedures
- The ageing population – as people live longer, the requirements for endoscopic treatments and procedures become more complex and, ultimately, contribute to a prolonged backlog of patients
- New procedures – as treatments advance, more procedures like bariatric surgery or the removal of bowel cancer can be done endoscopically rather than needing full surgery. This means more pathways are added to the endoscopy backlog and further staff capacity is required
- The National Bowel Cancer Screening Programme – a vital service which is currently available for 60-75-year-olds in England and Wales. However there are already efforts being made to expand this to 50-60-year-olds, which would bring a huge number of additional patient pathways into the service
- Lynch syndrome – a cancer syndrome that increases lifetime risk of bowel and other cancers and requires regular colonoscopy to catch pre-cancerous polyps in time. Predictions show we are only aware of a tiny minority of cases within the UK, so although increased awareness will improve patient survival, the colonoscopy requirements can be enormous with the average individual with Lynch syndrome requiring perhaps 30 colonoscopies in their lifetime
The solution to combat these pressure points is two-fold – patients need to be triaged more effectively from primary care and, when they do reach secondary care, more investment is needed in new procedural technologies that are less impactful on staff and physical capacity.
Ed Seward is calling for changes in the way endoscopy services are delivered, including supplying GPs with best-pratice flow charts to help inform pathways
Effective triage procedures
Whether a patient gets referred to secondary care, or is managed in primary care, can be dependent on support for GPs in terms of pathways of care and advice available.
Providing more support and advice should help keep patients in primary care.
As part of an outpatient transformation piece, myself and my colleagues in North Central London developed an outpatient care bundle for GPs.
This takes the form of best-practice flow charts for 10 of the most-common gastroenterological conditions, such as IBS, acid reflux, and constipation.
Each flow chart takes GPs through the necessary tests, scans, and warning signs that must be completed/observed before referral is necessary.
The inclusion of the Faecal Immunochemical Test (FIT) can also help keep referral rates down, with FIT tests results showing that 80% of patients with high-risk symptoms are ‘FIT negative’ and can remain in primary care with appropriate safety netting.
More education around the integration of these materials is also needed to not only aid the secondary care system in managing its backlog, but also help GPs to be in better standing to treat and advise patients effectively.
Technological innovation in secondary care
Procedures like colonoscopies and upper gastrointestinal endoscopies are invasive in nature, require a large amount of physical capacity, aren’t environmentally friendly due to the amount of water required for cleaning, and can result in further recovery capacity needed for patients that choose to be sedated.
Advanced technologies like the colon capsule and trans-nasal endoscopies, however, can be used to assist these issues.
By ensuring referrals are absolutely necessary, and that those who are referred are investigated and treated in an efficient manner utilising the latest technologies, we can cut the backlogs and alleviate the mounting pressure while still maintaining a patient-centred approach
By providing patients with a swallowable camera pill via a courier, the colon capsule can provide the same results as a colonoscopy, but can be undertaken at the patient’s home, guided by a nurse through a video call.
This removes the need for physical space, is far greener as the patient is less likely to need to drive to the hospital, avoids cleaning of the colonoscope, and gives flexibility to both the patient and clinical staff involved.
Trans-nasal endoscopies can likewise offer benefits.
The procedure is generally easier to tolerate as the tube is much finer and is inserted through the nose as opposed to the mouth.
It removes the need for sedation and so can be done in an outpatient office, freeing up a space in the endoscopy unit for another patient.
With the combined implementation of efficient patient triaging and innovative procedural technologies, NHS England can continue to make progress in recovering one of its most-crucial specialties.
By ensuring referrals are absolutely necessary, and that those who are referred are investigated and treated in an efficient manner utilising the latest technologies, we can cut the backlogs and alleviate the mounting pressure while still maintaining a patient-centred approach.
