Draft – for approval 10th Sept 2008
Regional Endoscopy Services Meeting
28th May 2008, 2.00-4.00pm
Bretten Hall Conference Room, Antrim Hospital
Minutes
Attendees
Dr Margaret Boyle / SMO DHSSPSDr Grant Caddy / Clinical Lead for Endoscopy, South Eastern Trust
Dr Michael Gibbons / Clinical Lead for Endoscopy, Southern trust
Ms Stephanie Greenwood
Mr Kourosh Khosraviani (CHAIR) / Regional Clinical Lead for Endoscopy, NICaN
Mrs Sarah Liddle / Colorectal Support Officer, NICaN
Mr Joe Magee / Deputy Director, Secondary care, DHSSPS
Dr Tracy Owen / Consultant in Public Health Medicine, SHSSB
Dr Colin Rodgers / Regional Training Lead for Endoscopy, NICaN
Mr Chris Thomas / Service Manager, OPMS, Belfast Trust
Apologies
Mr David Galloway / Director, Secondary care, DHSSPSDr Dermot Hughes / Medical Director, NICaN
Ms Liz Henderson / Lead Nurse, NICaN
Ms Catherine Hinton / Director of Elective and Acute Services, Northern Trust
Ms Rosemary Hulatt / Associate Director, Diagnostics, SDU
Ms Michelle Irvine / Director, SDU
Ms Beth Malloy / Ass. Director, Cancer, SDU
Mr Roy Maxwell / Chair of NICaN Regional Colorectal Cancer Group
Ms Cara McCay / Acting Director, NICaN
Ms Janis McCulla / Patient and Public Involvement Coordinator, NICaN
Ms Karen Simpson / Deputy Principal, DHSSPS
Dr Chris Steele / Clinical Lead for Endoscopy, Western Trust
1.0 Matters arising from minutes of last meeting
1.1 Dr Boyle noted that point MES_03 was inaccurate. The Chief Medical Officer has written to Dr Hugh Mullen, Director of Performance and Provider Development at the DHSSPS Service Delivery Unit, to ask him to set up an implementation group for Bowel Cancer Screening. This implementation group has not yet met.
1.2 There were no other changes to the minutes
Action: Sarah Liddle to amend minutes as per 1.1 above.
2.0 Bowel Cancer Screening
Priorities for Action Target
2.1 Mr Khosraviani stated that there were two concerns relating to Priorities for Action Target on bowel cancer screening. Firstly, confusion among Trust management, who feel it reads as though they are responsible for providing screening. Secondly, it is widely felt that the expected 10% reduction in mortality from colorectal cancer is unrealistic; the research evidence indicates that this level of reduction is only achievable over 8-18 years.
2.2 It was agreed that the matter of the 10% reduction in mortality needs to be raised at senior level in the DHSSPS.
Action: Dr Boyle and Joe Magee agreed to identify the best person for Mr Khosraviani to write to on behalf of this group. Mr Khosraviani to write, outlining research evidence.
Action: Sarah Liddle will raise the issue with Norma Evans, Chief Executive
of NICaN and representative of Trust Chief Executives.
2.3 Dr Boyle and Joe Magee stated that the process for the delivery of Bowel Screening will be managed by the Bowel Cancer Screening Implementation Group; Mr Khosraviani urged the Clinical Leads for Endoscopy to bring the message back to their Chief Executives that Trusts do not have to implement screening alone and guidance will be issued from the Implementation Group.
Approach to the Implementation of Bowel Cancer Screening
2.4 There was extensive discussion about the approach being adopted to introduce screening; Dr Rodgers stated that Trusts feel that they are simply being told to deliver screening; the issue of how screening colonoscopists will be accredited is controversial and it is not desirable to run the risk of alienating colonoscopists so that no one comes forward to be a screening colonoscopist. Mr Khosraviani agreed and stated that informal feedback from the service indicates that there needs to be considerable overlap between this group and the bowel cancer screening implementation group.
2.5 Dr Boyle said that both clinical and managerial input is needed to agree jointly on the best way to bring in screening; it should not be imposed. She also noted that there are implications across many aspects of the service from endoscopy to radiology, surgery and pathology.
Polyp Follow-Up
2.6 Dr Caddy noted that St Mark’s, a centre of excellence in endoscopy in England, was now entering the third year of polyp follow up following screening. There is no funding being made available to them to deal with polyp follow up this year, which is causing concern. They have a large number of cases, many of which have been generated through bowel screening.
2.7 Dr Rodgers added that this will also become an issue in Northern Ireland; unfunded FAP (familial adenomatous polyposis) screening colonoscopies/polyp follow-up is already an issue here.
Numbers of screening colonoscopies required
2.8 There was discussion on the number of lists required for screening; it will be in the region of between 900-1,000 colonoscopies per year, which evens out at around 36 or so lists per Trust per year, less than 1 per week.
3.0 Regional Workshop on 3rd April 2008
3.1 Mr Khosraviani reported that this had been a positive event which provided the opportunity for two way feedback between this Team and the Trusts. Dr Boyle gave credit to the organisers of the event.
4.0 Regional Capacity Audit Recommendations for Trusts
4.1 Mr Khosraviani stated that the draft recommendations had been sent round to everyone prior to the meeting. The following points were raised:
Recommendation 12: Equipment
4.2 It was stated that Trusts are currently putting 10 year equipment replacement plans together for DHSSPS Health Estates. Trusts are responsible for directing funds from their budget toward equipment replacement and maintenance. It was therefore agreed that it was not within the remit of this Team to raise this issue with the DHSSPS at this stage.
4.3 It was agreed to amend recommendation 12 to read ‘Equipment should be replaced as a minimum every 7 years. All equipment over 10 years should be replaced with immediate effect.’
Action: Sarah Liddle to amend.
4.4 Dr Rodgers emphasised that Training should be conducted using a scope guide, which is available from Olympus, the sole provider. The use of a scope guide is recorded as level A in GRS; Dr Rodgers stated that its use makes a massive difference to trainees ‘it is like night and day’. Joe Magee stated that as this was the case, and because the endoscopes to be used should be compatible with the scope guide, then ideally Olympus scopes should be used.
Recommendation 10: Upper GI Bleeding
4.5 It was noted that a recent BSG (British Society of Gastroenterology) document recommends that an out of hours upper GI bleeding rota should be considered by all acute hospitals. The DHSSPS has asked Trusts to submit plans for this, but to date only 1 Trust has done this (Northern).
4.6 There was discussion about the involvement of surgeons. Dr Rodgers stated that surgical trainees won’t be involved in the Northern Trust, because they are not trained to participate in a bleeding rota. This is because a general surgical trainee is competent at level 4 for diagnostic OGD and flex-sig but not for therapeutic OGD, which is what is required to provide cover on an emergency bleeding rota. They could only participate as a trainee, not as an independent operator.
Recommendation 14: Colonoscopy surveillance
4.7 There was discussion about the ability of Trusts to provide figures on the number on their surveillance list. These figures should be easily accessible for the PAS (Patient Administration System); the probable reason they were not is that these figures are generally held by individual consultants for their own patients and not entered onto PAS. Dr Rodgers stated that a pooled list linked to PAS would help to resolve this issue.
Action: Recommendation 14 to be amended to ‘Trusts must be able to demonstrate their failsafe procedure to ensure everyone due to be screened receives their appointment for follow-up screening colonoscopy in a timely manner’ (Sarah Liddle to amend).
4.8 Dr Rodgers commented that if the screening programme is responsible for all its own polyp follow-up, it will become huge and unwieldy.
Action: Sarah Liddle to find out how polyp follow up for bowel cancer screening patients is managed in other parts of the UK and feed back to the Implementation Group.
5.0 Patient and Public Involvement
5.1 Mr Khosraviani presented two papers arising from the recent focus group held with patient and public representatives; the first is a summary of feedback, the second a list of recommendations for Trusts. Mr Khosraviani stated that it was a useful exercise and will help ensure the service is more patient centred. Mr Khosraviani asked for feedback on the documents to be submitted to Sarah Liddle by Friday 13th June.
5.2 There was discussion on the key messages arising from the workshop. The first was the importance of good communication at the colonoscopy pre-assessment in the delivery of a patient focussed service, the second relates to the fear experienced by patients of the colonoscopy procedure. Different units have different reputations among patients and the need for a publicity campaign to advertise that services are being modernised and that the same high quality service should be available to all would help reduce fear.
5.3 Dr Rodgers added that the participating organisations had volunteered to help develop concise plain English patient information leaflets. Discussion followed about the EIDO leaflets which were felt to be good quality, while those produced by the BSG were felt to be long winded.
6.0 Outline Endoscopy Training Plan
6.1 Dr Rodgers tabled a copy of the Outline Endoscopy Training Plan he wrote. He asked Team members to read this and feedback to him. The full plan will be produced in September when training needs assessment and the Colonoscopy Practice Audit reports have been completed.
6.2 There was discussion about the procedure for those who are identified as underperforming through the colonoscopy practice audit (i.e. caecal intubation rate of less than 75%). This group are being asked to stop their practice in England. Dr Rodgers stated that there will be a similar approach taken here using Trust Clinical Governance structures where appropriate. Further information will be circulated about this in the coming months. Some operators have already voluntarily stopped providing colonoscopy; the audit has really focused attention on standards of practice.
6.3 A meeting has been held with Nurse Endoscopists to identify their training and support needs. The principle outcome was the need for two pronged appraisal supported by a line manager and a lead/supervising clinician. Dr Rodgers stressed that this group of practitioners must be supported through the Modernising Endoscopy Services Project.
7.0 Approval of (Screening) Colonoscopists
7.1 Mr Khosraviani tabled a discussion paper on the accreditation of screening colonoscopists. This sets out the varying approaches adopted in other parts of the UK. There was extensive discussion about the unwanted risks of creating a two tier colonoscopy service and the best way to ensure that all colonoscopists were supported in an equitable manner, including those who provide screening colonoscopies within the Bowel Cancer Screening Programme and within the current service, for example for FAP.
Mr Khosraviani stated that feedback received from clinicians on the two – tier model adopted in England has been negative. There was discussion about the importance of providing a high quality service across the region based on non-threatening peer assessment. There was recognition that adopting the English approach could create a scenario where colonoscopists would feel so threatened by the assessment procedure that they would decide not to come forward voluntarily to provide screening colonoscopies. Initial feedback from clinicians is that a two tier service is undesirable and that adoption of the ‘driving test’ in its current format would put people off applying to become screening colonoscopists.
7.2 It was agreed that some standard for colonoscopy practice, including screening colonoscopies, was required. The requirements for Northern Ireland were then discussed and agreed. These will be submitted as part of the discussion paper as recommendations to the Bowel Cancer Screening Implementation Group. The agreed criteria were as follows and apply to all colonoscopist rather than being limited to screening colonoscopists. The term ‘approval’ is recommended rather than ‘accreditation’. It is hoped that this will avoid the emergence of a two tier colonoscopy service.
7.3 Quality Criteria for Approval of All Colonoscopists in Northern Ireland:
§ Perform a minimum of 120 colonoscopies per year (this figure includes colonoscopies performed by a trainee under the supervision of the consultant)
§ Mandatory attendance of either the ‘Colonoscopy Master class’ or the ‘Colonoscopy Train the Trainer’ course, both of which include panel peer review DOPS (Direct Observation of Procedural Skills) using the endoscope imager.
§ Retrospective data for the preceding 12 months, demonstrating:
Caecal intubation rate of 90%
Patient comfort scores (snap shot)
Sedation level
Polyp retrieval by pathology
§ Completion of Multiple Choice Questionnaire (MCQ)
§ Agrees to attend a colonoscopy skills improvement course every 3 years
Action: Sarah Liddle to amend paper and Mr Khosraviani to submit to Bowel Cancer Screening Implementation group.
8.0 Progress Update
8.1 Mr Khosraviani provided a Gantt chart outlining the progress to date against
the project Milestones; everything is meeting its target apart from the Endoscopy reporting System. It has subsequently been estimated that this could take up to 2 years to implement.
8.2 Mr Khosraviani revealed that he and Dr Rodgers have been approached by
Weblogik (GRS creators) about the development of a bespoke endoscopy reporting system; this would be subject to the usual tender process.
8.3 Dr Rodgers advised Trusts not to progress with the procurement of their own
reporting systems. The aim is to have a unified system. Mr Khosraviani stated that SDU have committed to this programme of work and that he will meet Hugh Mullen to discuss this in the coming weeks.
8.4 The Nurse Lead for Endoscopy post has been approved as an 8a and will be
advertised soon.
8.5 GRS has been purchased and at present all units are in the process of being
allocated user names and password to allow them to start to enter data. Clinicians from Trusts stated that they would like to be allocated some resource to help them to gather the huge amount of data required to populate the GRS fields. Mr Khosraviani stated that it was up to Trusts to allocate this from their own resources.