Published on 24 August 2022
Recovering From the Pandemic – A New Approach to Training in the Endoscopy Service
How C&M Endoscopy Network and CMCA put in place a successful scheme to help tackle the endoscopy backlog
By Isobel Wenn, CMCA Project Manager, and Carys Kinsella, CMCA Cancer Workforce Lead
Endoscopy is a hugely important area of healthcare that is vital to the diagnosis and monitoring of diseases, especially cancer.
There are several types of endoscopy but all are methods to see inside the body using a long, flexible tube containing a small camera and light. Usually, endoscopy is used to look at the oesophagus (food pipe), stomach, or small bowel.
Patients have endoscopies to check for signs of cancer, especially if they are experiencing abnormal bleeding, continued indigestion, iron deficiency, or difficulty swallowing. Samples can also be taken from the patient and these biopsies are checked for signs of cancer.
Endoscopy services, including bowel cancer screening, have been under intense pressure for many years.
Several attempts have been made to increase capacity for both symptomatic and screening endoscopy, with some success. However, due to COVID-19, changes to bowel screening criteria, and an ever-increasing demand for services, the workforce reached critical limits, and waiting times for endoscopies increased.
The onset of the pandemic meant that the backlog in endoscopy services grew, not only because of increased staff sickness levels but also due to infection control measures that had to be implemented in the clinical settings where endoscopy was performed.
COVID-19 also impacted the training that staff were able to undertake. Face-to-face events to boost training levels would not be possible, so an alternative method to make up for lost opportunities and progress was needed.
A proposal to solve this problem was developed by the Cheshire & Merseyside Endoscopy Network (C&MEN) and the CMCA Workforce team. With funding provided by HEE, C&MEN commissioned CMCA workforce team to lead the delivery of a one-year pilot project.
It involved trialling an accelerated training model which would be used to target endoscopists nearing ‘provisional sign-off’.
‘Sign off’ is when an endoscopist can deliver endoscopy service lists (appointments) independently, freeing up other members of the clinical workforce and, in turn, enabling endoscopy units to see more patients.
The HEE funding enabled the creation of a team of four experienced gastroscopists, led by Dr Neil Haslam, Consultant Gastroenterologist and Joint Clinical Lead for C&MEN. The project educators travelled across C&M supervising additional training lists (which involves an experienced endoscopist observing a trainee, offering advice and support where required, to help develop their skills and expertise), to accelerate learning whilst complementing and supplementing C&M endoscopy units’ in-house training programmes.
The project educators committed to being available to supervise training lists for one day per week for the duration of the pilot project and the training model enabled the project educators to travel from hospital trust to trust, supporting trainees to train locally, with their own teams and seeing their own patients.
The first step of the project involved Dr Haslam working in collaboration with C&M endoscopy unit training leads to identify endoscopy trainees nearing provisional sign-off who would benefit from some additional support to help accelerate their progress.
Once the cohort had been identified, the project team, managed by CMCA, worked closely with endoscopy unit booking and scheduling managers across C&M to align trainee availability, unit list availability, and educator availability to schedule the additional training lists.
As the project progressed, additional training needs in polypectomy (a procedure used to remove polyps from inside the colon) were identified by the project educators and endoscopy unit training leads. As a result, a polypectomy training day was offered to all hospital trusts and took place in February 2022 at Liverpool John Moores University.
All respondents to the polypectomy training day course evaluation said they would recommend the course to a colleague, and comments left included… ‘Great course. The trainers were very experienced’ and… ‘This course was excellent! Please open it up to more trainees. The surgical trainees, in particular, would benefit greatly from this’.
To maximise the impact of the overall project, the duration of the pilot was extended by two months until the end of August 2022.
This gave more opportunity to provide additional training lists to trainees closest to provisional sign-off and has meant the two extra polypectomy training courses could be organised for C&M trainees. The extension also provided an opportunity for Dr. Haslam to provide ‘Train the Trainer’ sessions with interested trusts, providing multi-level events for both the trainees and trainers.
The project has had a positive impact on both the trainees and endoscopy units that they work in:
- All C&M Endoscopy Services have engaged with the pilot project and had additional training lists supervised within their endoscopy units
- Over 30 trainees from across C&M have had their training accelerated via the additional training lists
- 15 endoscopists have been provisionally signed off with the support of the additional training lists.
The clinicians who have been provisionally signed off may not have otherwise completed their training so quickly and sign-off will result in additional capacity and the avoidance of lost capacity across C&M.
Figures provided by the Joint Advisory Group (JAG) on GI Endoscopy confirmed that across C&M in 2021, 13 clinicians were provisionally signed off in colonoscopy. This pilot project began in July 2021, and within the first six months had supported five clinicians to provisional sign-off. Figures from JAG for 2022 are not yet available, however, since January 2022, this project has so far supported an additional 10 clinicians to provisional sign-off.
Clinicians who have been provisionally signed off as part of the project have provided feedback on their experience, which has been overwhelmingly positive. All said their level of knowledge has increased, their skill set has been enhanced and their level of confidence has grown.
Following the conclusion of the pilot, a full evaluation will take place for consideration within the North West Endoscopy Academy structure.
One of the trainees supported by the additional lists is Emma Quinn, a Clinical Endoscopist based at Mid Cheshire NHS Foundation Trust. Emma had several additional training lists supervised by project educators Dr Haslam and Paul Madigan, Nurse Consultant in Gastroenterology.
Emma said: “I found the extra training sessions extremely useful. I did a couple with Neil and five or six with Paul.
“It was a great learning curve having other people observe me ‘fresh’ without seeing me scope before. They picked up on small issues and offered suggestions, and ways to improve practice.”
“With Paul, we had been working on certain identified improvements, he gave set advice and instructions, and we could then look back at this post-session.
“This also gave me some confidence as I was nervous about scoping with ‘experts’ from other hospitals. However, I received a lot of positive feedback and did not feel under pressure from the trainers.”
Emma said that the training improved her clinical practice and the amount of time it took for her to achieve the endoscopy – known as the caecal intubation rate – ultimately speeding up her ‘sign off’.
Paul said: “As an educator, the trusts have all been welcoming to me and the trust’s leads have listened to our feedback. All endoscopy units work in the same way and have the same standards of service delivery which is reassuring.
“The trainees have greatly benefitted from the educator’s input and I have seen them develop their skills and confidence. It has been a pleasure to work with them all. The nurses in the rooms have all been professional and encouraged a learning experience for the trainees. It has been a pleasure to be part of the team. This format should continue as it has been a great success.”
Collaboration has been a key theme of this pilot. Scheduling the training lists – especially at the beginning of the project – required effort from the teams involved due to the complexity of aligning availability and building strong working relationships. Having clear communication has also been a significant factor in the testing of this training model.
Dr Haslam said: “The project was established to address both a lack of endoscopy training during the pandemic and the resultant shortage of endoscopists to help with the recovery.
“The programme has accelerated the training of 31 endoscopists with 15 having been provisionally signed off, which would not have been the case without the programme and the focus it brought to them.
“The feedback from trainees has been universally positive and many are now doing independent lists across the region.”
Project educator Ian London said: “I have found the training role very interesting and rewarding. We have many excellent trainees who are keen and learn quickly.
“I do hope this training continues beyond the anticipated end date as the focused training offered by the programme is very helpful to our regional trainees looking to develop their colonoscopy skills.”
Karen Lloyd, Senior Programme Manager of the C&M Endoscopy Network said: “The project has been very successful and by end of August 2022 there will be 15 clinicians signed off to deliver colonoscopy who otherwise may not have completed their training so quickly.
“This will result in additional capacity and the avoidance of lost capacity across Cheshire and Merseyside.
“I am sure these clinicians will have discovered cancers and polyps that could have become cancers in the future and lives will have been saved and extended by having this additional resource in our endoscopy family.”
Dr Jaiganesh Mohan, a gastroenterologist at Warrington and Halton Teaching Hospitals NHS Foundation Trust, who was one of the trainees who benefitted from additional training lists as part of the project, said: “The additional support for gastroscopy training has been beneficial and improved my skills. Excellent work. I very much appreciate it.”