Gastroenterology

Revisit working practices and service organisation to maximise workforce capacity. a) Introduce more six- or seven-day services and extended hours for inpatient ward rounds and endoscopy. b) Review consultant job plans to allow for more effective use of Direct Clinical Care (DCC) time, including by considering annualised job plans, timetable flexibility and backfill to allow for additional cover. c) Review consultant job plans to ensure there is a mutually acceptable balance in commitments to gastroenterology and to reduce general medicine commitments where possible. Where this increases elective work and leads to more radiology and pathology requests, ensure this is planned and resourced. d) Agree an appropriate allocation of leadership Programmed Activities (PAs) in relevant consultants' job plans to lead gastroenterology as a service, endoscopy as a service, training in endoscopy, and surveillance services (as appropriate for the trust's needs).

Review contractual arrangements for gastroenterology staff to create efficiencies and address long waiting times for outpatient services. a) Review consultant job plans to allow for more effective use of Direct Clinical Care (DCC) time, including by considering annualised job plans, timetable flexibility and backfill to allow for additional cover. b) Review consultant job plans to ensure there is a mutually acceptable balance in commitments to gastroenterology and to reduce general medicine commitments where possible. Where this increases elective work and leads to more radiology and pathology requests, ensure this is planned and resourced. c) Agree an appropriate allocation of leadership Programmed Activities (PAs) in relevant consultants' job plans to lead gastroenterology as a service, endoscopy as a service, training in endoscopy, and surveillance services (as appropriate for the trust's needs).

Optimise outpatient and day case services, maximising the effective use of clinical time. a) Look at ways to reduce Did Not Attends (DNAs) and cancellations using existing NHS Improvement guidance and NICE clinical guideline CG138 to help optimise capacity and reduce waiting times. b) Review pre-visit patient information provision to reduce the risk of patients having to be turned away at attendance or admission. c) Consider ways to personalise care planning around the patient's needs so they are more motivated and more able to attend appointments.

Consider triaging solutions to direct referrals appropriately and improve outpatient waiting times. a) Implement a Clinical Assessment Service (CAS) with senior clinical decision maker triage to review outpatient department referrals, and ensure there is budget and job-planned time allocated for running this. b) Clarify the differences between a gastrointestinal medical clinic and gastrointestinal surgery clinic in the Electronic Referral Service.

Work with primary care colleagues to improve awareness of and access to alternative services, support self-management and shared decision making with patients, and manage expectations and understanding of referral pathways and the value of interventions. a) Review access to services and consider whether to introduce additional services to ease waiting lists, such as supported self-management, direct access endoscopy (in line with NICE guideline NG12 on Suspected cancer: referral and recognition) or nurse-led dyspepsia clinics. b) Refer patients to appropriate resources for self-management and self-education (patient activation), and support shared decision making. c) Manage patients' and primary care colleagues' expectations and understanding about gastroenterology interventions to reduce the likelihood of inappropriate referrals.

Review and expand endoscopy capacity by revisiting working models, waiting lists and departmental resources. a) Monitor inpatient endoscopy demand, and explore using different models to manage demand, such as emergency and elective lists. b) Liaise with NHS England and NHS Improvement to review options, including possible financial incentives, to support trusts to expand their physical endoscopy capacity (that is: endoscopy rooms, recovery areas or other necessary space) to meet growing pressure on services.

Improve testing for and treatment of H. pylori. a) Ensure that H. pylori is tested for where patients have dyspepsia or upper gastrointestinal symptoms, but no cancer 'red flags' or other appropriate indications requiring gastroscopy. b) Ensure that where H. pylori is present, it is treated to eradicate it, and referral only made where symptoms persist. c) Ensure endoscopists check for H. pylori infection (using the rapid urease test where available), as appropriate during gastroscopy. d) Ensure H. pylori results are accurately recorded and coded.

Review usage of gastroscopy, particularly in younger patients (under 55s). a) Consider reviewing evidence and referral criteria for use of gastroscopies more generally in line with NHS England and NHS Improvement evidence-based interventions programme and existing NICE guidelines. b) Vet all referrals using NICE guideline NG12 on cancer referrals to ensure patients meet the criteria required. c) Alternatively, where direct-to-test pathways are used and not vetted, make the indications for gastroscopy very clear in line with NICE guideline NG12 on cancer referrals, to stop inappropriate referrals. d) Work with primary care colleagues to manage patients' expectations of the value of gastroscopy and improve shared decision making in line with NICE Clinical Guideline CG138 on patient experience. e) Consider use of transnasal gastroscopy for patients who might benefit from this, rather than rebooking for a procedure under unconscious sedation or general anaesthetic.

Improve pre-assessment and referral vetting for colonoscopies and increase access to CT Virtual Colonoscopy and CT where appropriate. a) Vet colonoscopy surveillance waiting list against the new BSG post-polypectomy and post-colorectal cancer surveillance guidelines to free up some capacity for higher-risk surveillance patients and for symptomatic referrals. b) Vet colonoscopy referrals and interrogate whether patients are being appropriately pre-assessed (including remote pre-assessment where appropriate). c) Review whether GPs are referring using the two-week wait pathway inappropriately, and work collaboratively with Primary Care Networks to ensure that NICE referral guidelines are followed correctly. d) Assess patients for wellness and frailty when deciding on the most suitable procedure, and discuss preferences with them, in order to tailor their care. e) Increase CT or CTVC capacity in co-ordination with radiology teams: any increase in demand will need to be adequately planned and resourced.

Analyse emergency and Post-Colonoscopy Colorectal Cancer (PCCRC) occurrences of cancer, keep a register of surveillance for high-risk patients, and remedy any identified issues to improve access to prompt diagnosis. a) Collect and analyse data on any new diagnoses of colorectal cancer as an emergency presentation, and conduct a Root Cause Analysis to identify themes to improve access to elective care to support earlier diagnosis. b) Perform an audit or Root Cause Analysis wherever a cancer may have been missed during colonoscopy, and use this to determine the most likely explanation, and to identify areas for improvement in the quality of colonoscopy services. c) Collect and share data to carry out a service-level review of rates of PCCRC, to identify ways to improve colonoscopy as a service. d) Avoid delaying surveillance for cancer in high-risk patients, such as those with Lynch Syndrome, for example by establishing high-risk patient registers where appropriate (as part of allocated leadership Programmed Activities (PAs)).

Review liver disease programmes, particularly focusing on early identification, proactive management and reduced occurrence of, and emergency admissions for, cirrhosis. a) Establish proactive programmes to manage patients with alcoholic and non-alcoholic liver disease, including: improved access to clinics; access to dedicated alcohol care teams and/or alcohol and drug misuse nurses; access to community detox; access to weight-loss clinics for patients with or at risk of Non-Alcoholic Fatty Liver Disease, potentially working with dieticians or diabetic management teams; screening of emergency admissions for high alcohol use, in line with NHS England and NHS Improvement prevention programmes. b) Register for and work towards Improving Quality in Liver Services (IQILS) accreditation or similar initiatives to share learning and best practice. c) Establish programmes to improve early identification of Alcohol-Related Brain Injury (ARBI), or of patients at risk, including better links to community detox. d) Review any variations in paracentesis complication rates and identify any underlying concerns, in order to share best practice and reduce risk of harm. e) Improve the day case rate for paracentesis.

Improve screening and treatment for varices. a) Offer screening gastroscopy for patients with cirrhosis to detect oesophageal varices - in line with NICE guidance. b) Ensure appropriate primary prophylaxis (such as beta blockers) and secondary prevention, including increasing day case rates of variceal banding, to reduce the risk of acute variceal bleeding.

Work with primary care to give direct open access to best practice fibrosis assessment. a) Increase use of either appropriate blood tests (in consultation with pathology colleagues), or scanning technology (such as fibroscan or equivalent) in line with NICE guidance on using fibroscans (MIB216), preferably giving GPs open access to book these scans.

Ensure awareness and consistent use of cirrhosis care bundles and discharge checklists. a) Ensure that all admitting staff across the trust are aware of cirrhosis care bundles, and use these consistently for patients who are admitted to hospital with decompensated liver disease. The bundle should include screening for and treating Spontaneous Bacterial Peritonitis (SBP). b) Ensure that all discharging staff across the trust are aware of and use the cirrhosis discharge checklist for patients being discharged after an admission with decompensated liver disease. c) Ensure all patients diagnosed with SBP are put on antibiotic prophylaxis, to reduce risk of recurrent infection. d) Improve engagement with regional liver networks which have key links to centres of expertise.

Ensure Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is performed only when necessary, as day cases where clinically appropriate, in sufficient volumes, and ideally with input from an ERCP multidisciplinary team. a) Only perform ERCPs with therapeutic intent - not solely as a diagnostic test. Consider less invasive Magnetic Resonance Cholangio-Pancreatography (MRCPs) or Endoscopic Ultrasound scan (EUS) for diagnosis (in consultation with radiology colleagues to ensure adequate capacity). b) Consider consolidating ERCP services with other centres at Integrated Care System level, especially if some sites are only performing very small numbers. c) Monitor data on repeat ERCPs: if a large number are carried out for stone disease, this may indicate the need for further training or consolidation. d) Ensure an ERCP MDT is established to review which patients require ERCPs and lower the risk of complications and mortality. This should include ERCP practitioners plus ideally EUS and radiology representatives. e) Ensure ERCP is performed as a day case, where clinically appropriate. f) Schedule ERCP procedures for morning lists where possible.

Ensure there is an effective programme in place for tracking and replacement of removable biliary stents. a) Ensure adequate tracking processes for biliary stents are in place, to reduce the likelihood that a patient is left with a biliary stent in longer than intended. b) Ensure discharge paperwork and patient after-care leaflets highlight symptoms of biliary sepsis, how to raise the alarm if these occur, and the importance of contacting the hospital if they do not receive an appointment to remove their stent.

Ensure there is sufficient proactive management for Inflammatory Bowel Disease (IBD) patients, to reduce emergency admissions and the need for surgery. a) Ensure new referrals with suspected IBD, with or without elevated faecal calprotectin results, are seen in an IBD or gastroenterology clinic within four weeks. b) Ensure IBD patients can easily access an effective IBD helpline and flare clinics, to reduce the likelihood of emergency admission. c) Ensure there is an acute severe colitis pathway in place and used consistently across the trust, with access to proactive management of inflammation and salvage therapy to reduce the need for surgery.

Review nutrition support infrastructure and establish nutrition support teams and steering groups as outlined in NICE clinical guideline CG32 on nutrition support for adults. a) Establish teams with dedicated nutrition specialist nurses - including recruitment of nutrition specialist nurses. b) Establish nutrition steering groups. c) Establish consultant-led nutrition ward rounds where possible. d) Ensure patients are screened in line with NICE clinical guideline CG32 on nutrition support for adults. e) Consider creating or engaging with regional networks for nutrition support to allow clinicians to share best practice, including creating specialist centres if appropriate.

Monitor complication rates across nutrition support services, and implement measures to reduce rates. a) Ensure Percutaneous Endoscopic Gastrostomy (PEG) 30-day mortality rates and Total Parenteral Nutrition (TPN) Catheter Related Blood Stream Infection (CRBSI) rates are carefully recorded and monitored, and put measures in place as needed to ensure correct case selection and share learning, aiming to reduce rates. b) Aim to use appropriately trained staff to look after TPN vascular access devices: this could be upskilled ward nurses (see below), vascular access nurses, dedicated nutrition specialist nurses or other allied health professionals. c) Upskill ward nurses in optimal vascular access device care, especially where dedicated vascular access teams are not in place. d) Consider co-locating patients needing parenteral nutrition in a dedicated area or unit where practical.

Work with pharmacy colleagues to carry out further investigation into any medicines recorded as unmapped or no-moiety medicines.

(Re)introduce and use initiatives and systems to share knowledge, resources and best practice to improve gastroenterology and endoscopy services. a) Sign up to or seek accreditation from existing quality initiatives where possible. b) Co-ordinate the sharing of best practice and business cases for gastroenterology and endoscopy services by establishing a GIRFT best practice library and learning platform. c) Use an Endoscopy Reporting System (ERS) that complies with National Endoscopy Database (NED) criteria to inform a national picture of clinical practice.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and by sharing best practice. a) Use sources of procurement data, such as Spend Comparison Services and relevant clinical data, to identify optimum value for money procurement choices, considering both outcomes and cost/price. b) Identify opportunities for improved value for money, including the development of benchmarks and specifications. Locate sources of best practice and procurement excellence, identifying factors that lead to the most favourable procurement outcomes. c) Use Category Towers to benchmark and evaluate products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs.

Use drinking water instead of bottled sterile water for manual flushing (via single use syringes) of scopes during endoscopy procedures, provided receptacle/water and syringes are routinely changed between patients.

Reduce litigation costs by application of the GIRFT programme's five-point plan. a) Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts would have received this information in the GIRFT Litigation data pack. b) Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk c) Once claims have been verified, clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trust's panel firm should be able to provide support. d) Claims should be triangulated with learning themes from complaints, inquests and serious untoward incidents (SUI) / serious incidents (SI) / patient safety incidents (PSI) and where a claim has not already been reviewed as SUI/SI/PSI, we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all frontline clinical staff in a structured format at departmental/directorate meetings (including multidisciplinary team meetings, Morbidity and Mortality meetings where appropriate). e) Where trusts are outside the top quartile of trusts for litigation costs per activity, GIRFT will be asking national clinical leads and regional hubs to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit.