UK endoscopy workload and workforce patterns: is there potential to increase capacity? A BSG analysis of the National Endoscopy Database.

Background: The lack of comprehensive national data on endoscopy activity and workforce hampers strategic planning. The National Endoscopy Database (NED) provides a unique opportunity to address this in the UK. We evaluated NED to inform service planning, exploring opportunities to expand capacity to meet service demands. Design: Data on all procedures between 1 March 2019 and 29 February 2020 were extracted from NED. Endoscopy activity and endoscopist workforce were analysed. Results: 1 639 640 procedures were analysed (oesophagogastroduodenoscopy (OGD) 693 663, colonoscopy 586 464, flexible sigmoidoscopy 335 439 and endoscopic retrograde cholangiopancreatography 23 074) from 407 sites by 4990 endoscopists. 89% of procedures were performed in NHS sites. 17% took place each weekday, 10% on Saturdays and 6% on Sundays. Training procedures accounted for 6% of total activity, over 99% of which took place in NHS sites. Median patient age was younger in the independent sector (IS) (51 vs 60 years, p<0.001). 74% of endoscopists were male. Gastroenterologists and surgeons each comprised one-third of the endoscopist workforce; non-medical endoscopists (NMEs) comprised 12% yet undertook 23% of procedures. Approximately half of endoscopists performing OGD (52%) or colonoscopies (48%) did not meet minimum annual procedure numbers. Conclusion: This comprehensive analysis reveals endoscopy workload and workforce patterns for the first time across both the NHS and the IS in all four UK nations. Half of all endoscopists perform fewer than the recommended minimum annual procedure numbers: a national strategy to address this, along with expansion of the NME workforce, would increase endoscopy capacity, which could be used to exploit latent weekend capacity.

Assessment of the role of the Edinburgh dysphagia score in referral triage in a national service evaluation of the urgent suspected upper gastrointestinal cancer pathway.

BACKGROUND: The British Society of Gastroenterology has recommended the Edinburgh Dysphagia Score (EDS) to risk-stratify dysphagia referrals during the endoscopy COVID recovery phase. AIMS: External validation of the diagnostic accuracy of EDS and exploration of potential changes to improve its diagnostic performance. METHODS: A prospective multicentre study of consecutive patients referred with dysphagia on an urgent suspected upper gastrointestinal (UGI) cancer pathway between May 2020 and February 2021. The sensitivity and negative predictive value (NPV) of EDS were calculated. Variables associated with UGI cancer were identified by forward stepwise logistic regression and a modified Cancer Dysphagia Score (CDS) developed. RESULTS: 1301 patients were included from 19 endoscopy providers; 43% male; median age 62 (IQR 51-73) years. 91 (7%) UGI cancers were diagnosed, including 80 oesophageal, 10 gastric and one duodenal cancer. An EDS ≥3.5 had a sensitivity of 96.7 (95% CI 90.7-99.3)% and an NPV of 99.3 (97.8-99.8)%. Age, male sex, progressive dysphagia and unintentional weight loss >3 kg were positively associated and acid reflux and localisation to the neck were negatively associated with UGI cancer. Dysphagia duration <6 months utilised in EDS was replaced with progressive dysphagia in CDS. CDS ≥5.5 had a sensitivity of 97.8 (92.3-99.7)% and NPV of 99.5 (98.1-99.9)%. Area under receiver operating curve was 0.83 for CDS, compared to 0.81 for EDS. CONCLUSIONS: In a national cohort, the EDS has high sensitivity and NPV as a triage tool for UGI cancer. The CDS offers even higher diagnostic accuracy. The EDS or CDS should be incorporated into the urgent suspected UGI cancer pathway.

National service evaluation of the two week wait upper GI cancer referral pathway

HTU-5 Figure 1The median interval from triage to endoscopy was: 12 days (IQR 8-18) for 2WW;14 days (10-26) for urgent (non-2WW);and 17 days (9-38) for routine endoscopy[Figure omitted. See PDF]ConclusionsTriage based on the BSG recovery guidance was 97% sensitive with a negative predictive value of 99% in diagnosing UGI cancer at 2WW or urgent endoscopy or CT scan. 6.6% of 2WW referrals were safely investigated routinely and over 9% of 2WW referrals required no investigation at all following triage. These findings should guide reform of the upper GI 2WW pathway to reduce the burden on endoscopy during and after the COVID pandemic.

The state of the gastroenterology and hepatology consultant workforce in 2020

IntroductionBritish Society of Gastroenterology (BSG) Workforce reports have identified widespread consultant vacancies, excessive workloads and insufficient training posts to meet current and future service demand. The COVID-19 pandemic has put further strain on an already overstretched and often demoralised workforce.MethodsThe Medical Workforce Unit of the Royal College of Physicians (RCP) undertakes an annual census of consultants each October. Data for gastroenterologists and hepatologists from the 2019 census, January 2020 RCP consultant wellbeing survey and the General Medicine Council (GMC) between 2012 and 2020 were examined.ResultsThe number of UK licensed gastroenterologists increased from 1,703 to 2,013 from 2014 to 2019. However, in recent years, fewer gastroenterologists have joined the GMC register annually (151 in 2014 and 115 in 2018). Consequently, 45% of advertised consultant posts in gastroenterology were unfilled and 8% of all posts filled by a locum in 2019, mostly due to a lack of applicants, with demand outstripping supply. There has also been a smaller increase (9% versus 14%) in gastroenterology trainee numbers compared to other medical specialties between 2012 and 2020. The average number of population per full time equivalent gastroenterologist in the UK is 43,913 but there are significant regional variations with some regions much more poorly served (Thames Valley 63,456, North Wales 59,444, Kent, Surrey and Sussex 50.974, and East of England 50,487).Gastroenterologists work a mean of 1PA unpaid in addition to contracted PAs. This leads to gastroenterologists saying they always, or most of the time in 59% work excessive hours and in 61% have an excessive workload. Gastroenterology is the major specialty at highest risk of burnout with lower (worse) mean mental wellbeing scores. Consequently, 51% of gastroenterologists reported that work affected their relationship with their partner and 53% with their children in the past year. 52% described their morale in 2019 as being worse than in 2018. 18% of gastroenterologists reported feeling bullied or harassment over the past year by managers or fellow consultants. Despite these issues, 87% of gastroenterologists reported they were always or often satisfied with specialty work, but only 21% with general internal medicine work.ConclusionsUnfilled consultant vacancies, high workloads, low wellbeing scores and morale were evident in gastroenterology and hepatology even before the COVID-19 pandemic. Gastroenterology is the major medical specialty at highest risk of burnout. At a time when the NHS workforce is under increasing pressure, these issues must be urgently addressed to improve the working lives of gastroenterologists and hepatologists.

The Gastroenterology and Hepatology Higher Specialist Trainee workforce 2020 – the issues our trainees face

IntroductionThe COVID-19 pandemic has had a significant impact on workforce, morale and training. Even prior to this, there were considerable challenges facing gastroenterology training due to the shape of training initiative.MethodsThe Medical Workforce Unit of the Royal College of Physicians (RCP) undertakes an annual census of higher specialist trainee (HST) physicians each December. Key issues affecting gastroenterology and hepatology trainees combined in the census and General Medical Council (GMC) data from 2012 – 2020 were examined.ResultsGastroenterology national training numbers have gradually increased from 673 in 2012 to 734 in 2020. Of those who began gastroenterology training in 2012, 24% now remain in training, 65% have completed their CCT and 5% have left training.14% of gastroenterology HSTs reported being bullied or harassed at work. Gastroenterology ranked 6th among medical specialities on this issue. Although HSTs were less likely to experience bullying or harassment than consultants, there were higher rates reported by Black, Asian and minority ethnic (BAME) than white HSTs (17% versus 11%). BAME HSTs were also more likely to have experienced discrimination than white HSTs (9% versus 7%), and women HSTs were three times as likely to experience discrimination as men (15% versus 4%).Gastroenterology HSTs ranked 5th most at risk of burnout among medical specialities, with rates of moderate and high burnout risk of 39% and 12% respectively. Male HSTs reported slightly greater risks of burnout than female HSTs and BAME HSTs reported markedly higher rates of high burnout risk than white HSTs (15% versus 9%). 62% of HSTs said that work had impacted on their relationship with their partner and 58% with their children. 33% of trainees reported a deterioration in morale since the previous year and only 20% an improvement.82% of HSTs said they found their specialty work satisfying always or often, but only 22% their general internal medicine work. A smaller proportion of gastroenterology HSTs work less than full time (LTFT) than in other medical specialities (11% versus 17%). When asked if they wanted to train LTFT if given the opportunity, a surprising 46% of gastroenterology HSTs said they would.ConclusionsThere were huge challenges facing gastroenterology HSTs before COVID-19. Worrying trends in bullying, discrimination, morale and burnout need to be addressed urgently. As time for training shortens, we must improve trainee experiences and the quality of training to protect the future gastroenterology workforce.

Insight from patients and healthcare professionals on the implementation of virtual clinics in patients with inflammatory bowel disease.

Introduction: During COVID-19, the management of outpatient inflammatory bowel disease (IBD) changed from face-to-face (F2F) to telephone and video consultations across the UK. We surveyed patients with IBD and IBD healthcare professionals (HCPs) to evaluate the impact of this abrupt transition on patient and HCP satisfaction outcomes, including the barriers and enablers of this service. Methods: Patient satisfaction surveys were sent to patients who had a telephone consultation from May to July 2020. A second survey was sent to IBD HCPs across the UK. Questions from both surveys consisted of a mixture of multiple-choice options, ranking answers as well as short-answer questions. Results: 210 patients and 114 HCPs completed the survey. During COVID-19, there was a significantly greater use of telephone, video or a mixture of consultation. F2F consultations were consistently preferred by patients, with 50% of patients indicating they did not want the option of for video consultations. Patients were more likely to prefer a telephone consultation if they were stable and needed routine review. Significantly fewer HCPs (5.3%) intend to use F2F consultations alone, preferring the use of telephone (20.2%) or combinations of telephone/F2F (22.8%), telephone/video (4.4%) or combination of all three consultation types (34.2%). 63% indicated they intend to incorporate video consultations in the future. Conclusion: Telephone and video consultations need to be balanced proportionately with F2F clinics to achieve both patient and HCP satisfaction. Further research needs to be done to explore the use of video medicine in patients with IBD.

The UK physician workforce: one-third at increased risk of death from COVID-19.

INTRODUCTION: 21% of NHS staff are from Black, Asian and minority ethnic (BAME) backgrounds yet account for a disproportionately high number of medical-staff deaths from COVID-19. Using data from the published OpenSAFELY Collaborative, we analysed consultant physicians to determine those at increased risk of COVID-19 related death. METHODS: Data from 13,500 consultant physicians collected by the Royal College of Physicians were analysed to determine those at an increased risk of death from COVID-19, assuming no comorbidities. RESULTS: The data reveal a picture in which a third of consultant physicians have a hazard ratio (HR) >1 for dying from COVID-19; one in five have HR >2; one in 11, HR >3; and one in 40, HR >4. Of concern are the risks to male physicians aged ≥60 with HR >3.8. Sub-specialties including cardiology, endocrine and diabetes, gastroenterology, haematology, neurology and rheumatology have a greater risk profile due to high proportion of men, physicians of older age, and proportion of BAME individuals. CONCLUSION: A third of consultant physicians have an increased risk of a COVID-19-related death, and one in five have a higher relative risk (HR >2). The risk is mainly driven by age, gender, and ethnicity, the risk is highest in male consultant physicians over 60, especially from BAME backgrounds.