The Endoscopy Action Plan (EAP) sets out a range of actions that will deliver changes in management of endoscopy services. The actions are defined as short to medium-term with clear deliverables and within the framework of the WTIP. While diagnostic targets are not explicitly mentioned within the WTIP, there is a clear expectation that there will be no patients waiting over six weeks by Spring 2022. This will require a focused programme of work to accelerate both new and existing actions already underway.
Increasing capacity across the system
All NHS Boards are experiencing increased demand on endoscopy services, in particular there is increased demand on colonoscopy services following the introduction of faecal immunochemical testing (FIT) into the Scottish Bowel Screening Programme in November 2017. While increases in participation are to be welcomed there has been an increase in positivity with the new test which has resulted in a 100% increase in referrals to endoscopy services for screening patients.
This plan will co-ordinate and use capacity across the country, including use of the independent sector in a structured way to reduce waits and ensure the highest priority patients continue to be prioritised. This will provide additional short-term capacity to support the improvement projects underway to increase capacity in the longer term.
The availability of a trained workforce is critical to the successful delivery of the EAP. The plan commits to the continued training provision for nurse Endoscopists across NHSScotland and to work with the Scottish Access Collaborative to develop Advanced Nurse Practitioner posts to ensure patients are seen appropriately and quickly.
- Reduce numbers waiting over six weeks through additional clinics and scope sessions.
- Support the expansion of nurse endoscopist training.
Increasing effective use of existing capacity
The EAP will build upon the existing Scottish Access Collaborative and ensure that there is clinical leadership throughout the plan. There is variation in the compliance with clinical guidelines for referral into endoscopy services and for follow-up and surveillance patients. The EAP will ensure that the revised Scottish Referral Guidelines for Suspected Cancer are embedded in routine clinical practice and will develop clinical consensus of revised guidelines for surveillance patients.
The EAP will ensure that relevant clinical pathways such as haematuria pathways are reviewed and redesigned to improve outcomes for both patients and clinicians. Coupled with clinical validation this will help ensure that patients are on the right clinical pathway at the right time and reduce unwarranted variation and increase capacity.
- Implement the revised Scottish Referral Guidelines for Suspected Cancer.
- Develop and implement guidance for surveillance and follow-up.
- Implement three stage clinical waiting list validation.
- Introduce Active Clinical Referral Triage (ACRT).
- Reduce variation in the availability and adoption of effective endoscopy management systems, to aid booking scheduling.
- Review relevant clinical pathways via the Scottish Access Collaborative Framework.
Embedding wider improvement
There are particular pressures on colonoscopy services. Many patients who are referred for colonoscopy have vague gastrointestinal symptoms. Patients who have bowel symptoms suspicious of cancer or serious bowel disease are referred for endoscopy as the first diagnostic test. However, the symptoms that are associated with bowel cancer are frequently associated with much less serious causes such as haemorrhoids and irritable bowel syndrome (IBS).
A quantitative faecal immunochemical test for haemoglobin (qFIT) has been proven to be effective at detecting trace amounts of haemoglobin in faeces (a risk factor for cancer or serious bowel disease).The potential to use qFIT to aid referral from primary care into endoscopy services has been piloted across NHSScotland. A clinical learn and share event was held in December 2018, to share best practice and gather clinical outcome data to inform the national approach to qFIT roll-out, and a further event is scheduled to take forward the implementation of recommendations from this group.
There is variation in the management and booking of patients for endoscopic tests across NHSScotland. New management information including urgency of referral and time bands will be developed to inform effective booking and management for new and surveillance patients. The endoscopy management systems currently used to capture clinical outcomes have the potential to aid in the effective booking and scheduling of all patients and will be explored.
The National Bowel Screening Programme audit has demonstrated a significant variation in practices and performance between units within Scotland. Audit stimulates continuous improvement in processes and patient outcomes and provides a knowledge base of best practice to improve management and efficiency of endoscopy services. We will work with NHS Boards and Healthcare Improvement Scotland (HIS) to audit endoscopy units and explore accreditation.
- Introduce weekly management information including source of referral, numbers waiting by time band and activity.
- Implement qFIT to support referral from primary care.
- Audit endoscopy units and explore accreditation.
- Pilot and invest in new technologies as they emerge.
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