Health and Social Care Committee

Yes. Hello, good morning. Thank you for having me. My name is Mark Jarvis. I'm a consultant gastroenterologist at Basildon hospital and I'm accreditation chairman for the joint advisory group on gastroenterology. I speak on behalf of JAG, the Joint Advisory Group on Gastrointestinal Endoscopy, today.

Thank you for being with us.

I'm Jeff Turner. I'm representing Health Education and Improvement Wales in my role as deputy clinical lead for the endoscopy training management group, but I'm also a consultant gastroenterologist and also part of the single cancer pathway team in the Welsh cancer network.

Good morning, bore da. I'm John Green. I'm here in my role as the current president of the Welsh Association for Gastroenterology and Endoscopy, but for the record I'm also one of the clinical leads of the national endoscopy programme. I'm a consultant gastroenterologist and a colleague of Jeff's in Cardiff and Vale, and at the last inquiry I was doing the role that Mark's doing—I was the chair of the group in JAG 2019.

That's it, thank you, and welcome back to committee. Thanks both for being with us also today as well. Do we have a clear picture of the current endoscopy workforce now, and also what we might need into the future? Who would like to tackle that first? I'm looking around.

I'm aware that, as part of the national endoscopy programme, there is work under way and ongoing looking at the workforce and they're developing a live dashboard that gives information across health boards. There's also information from previous JAG censuses and also there's another JAG census that's due to include workforce that's due to, I think, be sent round over the next couple of months. So, I think there's information that's becoming available that should inform training as well in the future, as well as the workforce gap.

So, just for my understanding as well, do you think that we have a clear picture of the workforce, the numbers in the workforce throughout endoscopy services now? Do we have a clear picture of that? I ask that again because we had some contradictory evidence in our last session.

I think we're developing an understanding, but I don't think we're in a position at the moment to be able to give accurate information across workforce areas. I have seen some of the work that's being undertaken and it is working at pace. So, I think that, alongside the JAG census that's due to be undertaken over the next couple of months, should provide us with robust data following that.

And it's good to know that that is in progress, but just give us an understanding of why that data isn't available now, I suppose.

I'm not directly involved in the workforce areas. I suppose I can only comment on work that I appreciate is under way.

Okay, that's fine. I can see Dr Green wanting to come in.

I think it would be an area that—. I have watched the recordings of this group from the last couple of weeks ago, and I heard the comments made. I think it would be an area where it would be of great benefit to have publicly accessible data, which would help to show where we are. There is a dashboard that's in its infancy that the NEP, national endoscopy programme, have been creating around the workforce across Wales. It's a very dynamic thing. This changes week by week in terms of the different constituent members of the workforce in endoscopy, from the endoscopist, nurses, admin, who have a critical, crucial, role as well, and the sort of changes in service provision that happen all the time. So, I think having a dynamic dashboard that's accessible, alongside other things that we do have at the moment that we can get, in terms of activity data and waiting list data, would be really beneficial. I think that would be a really helpful thing, and I think it is in its infancy, and Jeff's right that the benchmarking data across English services that comes from the JAG census, which I think this is its third or fourth iteration, is really helpful stuff, and the data from the previous surveys are there to show where we were in terms of our numbers. But I think that would be a resource that would be great if it could be available as a regular, live sort of thing, really.

Sure. Thank you. Just give us, or give me, as a lay person, an understanding of the roles within endoscopy, because I can see there's mention of clinical nurse endoscopist roles. Just explain this.

Yes. I think, like any workplace, you require a whole range of different workers to make things work. Everybody thinks of the person doing the procedure, but they are a very small cog in the wheel, as it were. To make things work effectively, you need the whole team to be there and functioning effectively. So, we can't do what we can do without having a full set of nurses in the room and in the service to guide the patient through their journey. We need the administrative booking team and managerial support to actually make sure things effectively work, and also the team who, for example, decontaminate the equipment. So, you have to have all those things in line to actually do the front-of-house procedure, as it were.

The question you mentioned about clinical endoscopists—. So, traditionally, endoscopy has been a role that's been undertaken by doctors, either of a medical gastroenterology background or a surgical background. But some years ago there was a move, which has been led mainly in England, around—. Initially, they were called nurse endoscopists, so they were nurses who took an extended role doing diagnostic endoscopy. But that terminology wasn't quite correct, because there were non-nurses, for example, operating department practitioners who worked in theatres, and also now we're getting people who are physician associates, people from a range of backgrounds, who want to do endoscopy, and they're now called clinical endoscopists. So, these are nurses by background who aren't nursing, they're actually doing the procedure. And there is some really good work showing—. Professor John Williams, who is retired now, from Swansea, did some great evaluatory work showing how effective they were and how well-received they were by the patients—

Are these roles that you mentioned—? You mentioned a number of different roles. Are they perceived as being attractive or less attractive? I ask that question in terms of attempting to try and recruit people to these roles.

Yes. Again, it's part of the whole challenge that we have with our workforce, with the nursing numbers, isn't it, across the whole health service. There's a lot of work—the national endoscopy programme have put together a sort of a marketing campaign to attract nurses to Wales to do endoscopy. So, they've come up with some quite good social media-type campaigns to do so, and we've had—

Are they working, those campaigns? Are they working well, as you'd like them to?

Well, I was just at a meeting—. They've done the work, and that was the question, actually, 'Has that translated into benefits?' I know the team are doing some evaluatory work around that to see what happened. Certainly, in our own service locally, we've had a really welcome influx of overseas nurses, really, really excellent, excellent nurses—we can testify that from own service—who've really helped to support the development. But the clinical endoscopy role is something that is very much integrated in UK services. There are actually more of them in the English health service than the Welsh service, but there's been a real push. We've had three cohorts in Wales now of training these extended nursing roles to help support the workforce, and they're fantastic, really good colleagues of ours, really effective and really well valued.

Thank you. I'll just bring in Dr Jarvis. Anything you want to comment on anything that I've asked or anything that's been said?

I can't overemphasise, actually, how important the nurse endoscopist or the clinical endoscopist role is. They really are a great asset to endoscopy. It gives potential to greatly increase endoscopist numbers and greatly increase the number of procedures that we do. In areas that are struggling for volume of work, it's very important. In my hospital, we've trained a whole series of nurse endoscopists who perform to a very high level and really plug the gap and have allowed us to increase our output. I can also confirm that the JAG census has been rewritten slightly and is out now, I believe, so the data should be back soon and published.

Lovely. So, before I move on, I think, Dr Turner, you wanted to come in, but I'm just interested also to hear about your views on the recruitment campaign as well.

Yes. I think it's had a really positive impact in raising the profile of endoscopy throughout Wales, again, across workforce groups, using social media platforms.

And I think, in terms of clinical endoscopists, we've got a very good national clinical endoscopist training programme; it's in partnership with Swansea University, and we've actually doubled the number of clinical endoscopists in Wales over the last few years. We've got three new clinical endoscopists that are being trained currently, which includes a physician associate, as we mentioned.

So, I think we've got a good reputation for training, so I think that helps with retention and recruitment as well in the future.

That's lovely. Before I come to other Members, don't feel you all have to address every question that's put, but, if you want to come in on something, just indicate to me as well, especially Mark on the screen. I'll keep an eye on you as well if you want to come in at all. Sarah Murphy.

Thank you, Chair. Thank you all for being here this morning. I'm going to ask some further questions about training. So, we've heard some concerns about the current endoscopy training infrastructure—

I can't hear, I'm sorry.

Sorry, Mark. Thanks for saying.

It isn't going red, to be fair. Is it meant to? Joyce's is on.

Can you just turn—? Sorry, a moment. Just see if yours comes on now. Wait a moment. No. In that case, I think if you—. I'm doing something that IT probably are going to tell me I'm wrong, but, Joyce, do you want to move yours slightly across? It looks like there's a problem with your speaker.

Joyce's has gone off as well now, though.

It will come on in a minute again, I think.

Here. Try this.

Now it's on, and, if you can lean forward as well, Sarah, that might help as well. There we are, Sarah.

Okay. Can you hear me now, Dr Jarvis? Okay, wonderful.

Perfect, thank you.

I'm just going to ask some questions around training. So, we've heard some concerns about the current endoscopy training infrastructure, including reference to length of training and ability to access training across Wales. However, I would say as well that, overwhelmingly, we've heard a lot of support for the clinical endoscopy training academy and how this can improve access to and accelerate the training pathways. So, could you give us some insight into how you see this panning out, and also any anticipated timescales for the establishment of the academy? Probably best to come to you, Dr Turner, first.

So, I think it's fair to acknowledge there are challenges, and obviously COVID's had an impact on that across the workforce. There have also been some changes in the training structure nationally, so, for medical endoscopists, the length they've got to train in is reduced down to four years, and also, based upon current evidence, the training pathways have evolved as well and recently been updated. So, for upper GI endoscopy, people need to undertake more procedures before they can be accredited, and similar for colonoscopy as well.

In terms of the different areas of the workforce, we've mentioned admin and managers. There is a collaborative training programme that's been put together with academies in England, which is really exciting. For nurses as well, we've delivered for over 100 nurses across Wales one of the foundation courses that's due to be a JAG requirement as well, and also increased our faculty size to help manage that.

And I think, in terms of delivering endoscopy training, we've mentioned about clinical endoscopists, and the benefit of accelerated training. We've also got something called SPRINT, a structured programme of induction and training, in Wales, which is for upper GI endoscopy, and again that's an accelerated training programme that we know can really reduce the time it takes to train people. And we have submitted an outline business case to HEIW execs to support a potential academy Wales model for training in endoscopy, and, again, that will support the delivery of core courses that people require, so JAG courses, but also offer across Wales accelerated training. So, we think that'll have massive benefits in the future.

And timescales?

So, it's been submitted, and, if it's supported by the execs, hopefully we'll develop a full business case, and, if that's supported, it'll be a phased approach over the next four years.

Okay, excellent. Thank you very much. Dr Green or Dr Jarvis, did you want to come in on this? If not, I've got a supplementary.

Don't feel you have to, if you—

Yes.

I've got nothing particular to add.

Okay, wonderful.

That's lovely. Do want to come in on your second question, then?

Yes. Just to add on, then, is that we have also heard concerns that there are varying and restrictive HR policies in different health boards, and this may mean that someone's training and skills aren't always recognised, and this may also be contributing to workforce attrition. Is this something that you've seen and that you recognise?

I think, for medical trainees, they're looking at a more flexible approach as part of the training programme so that they can work across health boards. I'm aware that, if you work across health board boundaries, sometimes you do require honorary contracts. I've not been aware of it as a major issue, though, I must admit.

Okay. Thank you very much. Dr Green.

I think it's fair to say that there is a bit of a challenge in working outside your health board, in clinical practice. There's a process to go through, which you can go through but it takes a bit of time. But I think one of the messages we're keen to portray is the importance of people being able to work and train beyond the health board that you're based in, by joining up processes. It's a bit of a faff to go through things, a little bit, so I think that could be improved, and I'm sure that's doable. Again, it goes a little bit more with regional endoscopy working and working a little bit outside your own health board barriers to benefit the population.

Just one thing about training I'd like to say, which I think we'll come to with Mark later on, but another big benefit of having a JAG peer-review visit is that training is a big focus of that process, and that's the training that people receive in the service themselves. And that's the whole of the workforce, not just the people doing the procedures. It's the nurses and it's the staff as well. And that's another important factor as to why we need to have JAG accreditation and peer-review visits.

Thank you. That brings me to my final question. We've also heard that existing trained endoscopy staff need to be freed up to focus more on endoscopy, rather than being pulled into other clinical duties. How do you see this being achieved?

This challenge is because our colleagues—. Most people who do endoscopy do lots of other things as well. So, they're involved in other aspects of gastroenterology, surgery, general medicine, so they are pulled in various directions. And there are also really only a finite number of endoscopy lists that one person should be doing anyway during a week because of RSI, and they can also add value to lots of other areas of the service. So, I think it's down to individual job planning and things within health boards, looking at the other pressures and constraints that individuals are under. But, I do think we have to recognise that people who do endoscopy have got a skilled trade that they can offer the population, as it were. So, I think, where possible, you should maximise the opportunities for those people to do that skill. But, obviously, the other service pressures need to be borne in mind. So, I think it's very much down to individual job planning. But, I think the message should be there that we should be maximising the opportunities for those individuals to do that work.

Dr Turner.

I was just going to come in as I think that's one of the benefits of accelerated training as well, because you can ring-fence with the health boards, with training groups, time potentially away from your hospital base, and it's a real focus. And that really pushes people up the learning curve. We know that people can complete their training several months earlier, and that has a service benefit then, because once people are signed off, they can start delivering endoscopy independently.

That's excellent. Thank you very much, and thank you, Chair.

Thank you. Joyce Watson.

Good morning, all. I want to particularly ask questions about the JAG accreditation. You've mentioned barriers—some of them have already been talked about—in achieving that accreditation. Is there a big variation between the health boards?

Dr Green. Oh, I can see Dr Jarvis wants to come in.

Do you want to start, Mark, and I'll follow on afterwards?

Yes. I think there is quite a lot of variation in hospitals and in boards as well. My colleague Debbie Johnson did a report in 2019 and then revisited it again. There were a number of hospitals that were looked at—I think 13—that hadn't achieved accreditation. And they developed a score board across those, looking at the ones that were the lowest hanging fruit for getting accreditation. I think they found a whole series of different hospitals and different boards that were struggling, which had different challenges. I'm afraid I'm not sure which boards had the particular challenges, but there was certainly a group of problems across them, and a group of problems across different hospitals too.

Thank you, Mark. Just to say that I can't hear at all, I'm afraid.

Sorry, nobody was saying—. There was a gap in the proceedings for a moment. Dr Green.

Yes. I was just going to come back with some insight from Wales, and firstly to say that we work very closely with JAG through the national endoscopy programme. We have regular meetings and lots of really good dialogue, so thank you to Mark and colleagues for supporting us. A number of services in Wales are JAG accredited and have maintained JAG accreditation through the pressures that we've all been in through the health service in recent times, to their great credit. Through Mark's visits, we felt it was good for the national endoscopy programme to have all the services looked at by an external assessor to benchmark where they were and to give them some help and guidance about what needed to be done for them to move towards accreditation, with a strong viewpoint from our community that we should all be assessed, because this is a supportive, facilitative process that helps us and helps our patients. In that process, about eight units in Wales were recognised as being the closest to getting accredited. There are a number of units that are some distance away, and that's largely because of the physical infrastructure that needs quite significant investment to actually make it compliant with not safety issues but privacy and dignity standards. They are safe services, just to make sure that's really clear. They are safe services, but the whole pathway is very much around—. Because you're going through a service where you may be unclothed, in a gown, the whole privacy and dignity aspect needs to be optimised. So, although the people working in those services do what they can do to optimise things, some are constrained by it.

So, there were eight services that were identified by Mark's colleagues as being nearly there. Of course, that was done at the end of 2019, the beginning of 2020, before we went through what we went through in 2020 and beyond. Those services are continuing to work towards it, and one of the services actually put themselves forward to having a peer review in the near future, and we're hopeful, by supporting them through the work from JAG and from the national endoscopy programme, that a number of those other eight services will also go through in the next 12 months to have visits done. But we do have to remember that there are some that are still very constrained, and there needs to be almost a strategic decision whether they are heavily invested in, or that the endoscopy is housed elsewhere within that geographical area.

I was going to get to geographical areas, because I'm Mid and West Wales, and we have a number of hospitals and they're all in the rural area. I was going to ask, whilst you've identified that it's basically dignity and respect, is it achievable for those hospitals to offer that, given the state of the estate and the configuration of the estate where they're carrying out procedures, in your view?

The west Wales hospitals are actually—. Hywel Dda have actually got three accredited services, so you're well served there in terms of being peer reviewed in west Wales. The answer to that is a variable answer. There are some that are able to partly negate against things by measures taken within the service with temporary solutions, but there are some that are recognised, both from our services and outside, to be needing to be very, very majorly refurbished to actually make the whole pathway compliant with standards, but there are ways around that people do to minimise that disruption. For example, JAG is keen that patients dynamically can give their feedback through surveys, and that includes questions about privacy and dignity. If things are highlighted within the services, then those individuals do what they can do to try and improve what they can provide within there. I think most people are doing what's possible within the infrastructure they're within, yes.

And are they getting targeted support? You've identified the issue—you need to perhaps target that support. Are they getting that? That's one question. And then, following on from that, are the health boards giving sufficient priority to achieving JAG accreditation?

In terms of the targeted side of stuff, it's an issue that the national endoscopy programme and the group that I'm involved with through that group have regular meetings and conversations with health boards on. There's a dialogue that goes on there. There's executive involvement within those conversations as well, so that is very much on the agenda. I think, from some of the directors, from the health Minister, et cetera, there is an expectation that Welsh services go through the JAG accreditation process, so it's very much on the agenda when you talk to people of high level within the health boards. So, I think it has had, certainly, an increase. Certainly, since the initial inquiry and work afterwards, it's become more of a priority and more on the agenda. But, again, it's in the context of a slightly difficult situation within the health service.

Maybe the question is to Dr Turner: in your view, are health boards giving sufficient priority to obtaining the JAG accreditation? I don't think he heard me.

That could be perhaps to Mark as well. I don't know who would want to pick up that question.

I think there is a drive to gain accreditation, and I think, within the system, working with John, and Sara Edwards, there is clearly a good level of knowledge as to where work needs to be done to get accreditation. But it is still a big challenge, and I think there could always be support.

In terms of what needs to be done, I think there has been some modelling regarding capacity and volume. That's always a challenge for services throughout England and the devolved nations, to perform the number of procedures that are required. There is the infrastructure issue, which I think services are probably aware of, or there is a knowledge within the service as to what needs to be done. There are also some issues with leadership and support. I think there could always be more support to hospitals at a very high level, though there has been good engagement, and I've enjoyed the work that I've done with my Welsh colleagues. I think the level of engagement is quite good, but there could always be more.

Thank you.

Thank you, Joyce. Rhun ap Iorwerth.

Thank you very much and good morning. I'd like to look at issues relating to resilience and capacity within the system. A response that's been used often is insourcing and outsourcing contracts with the private sector. But, by definition, that is something that has to be short term. It is something that it's possible to become completely reliant upon. So my question is this: how do you transition from that reliance on insourcing and outsourcing to a system that's more sustainable?

Diolch. I'll start. I'm sure Mark will be able to give some good UK perspective as well, because insourcing is done very widely throughout the United Kingdom, not just in Wales.

I think it's important to recognise we've come from a situation where our number of procedures per head of population in Wales is historically a low number. So, there was a big British Society of Gastroenterology audit in 2011 looking at the number of colonoscopies per head of population, and we did, at that stage, 23 per 100,000. It was 30.9 in England and 46.8 in Scotland. So, historically, our numbers of procedures have been low.

In terms of our rooms, we've come from a situation where we have at present about six or seven procedure rooms per health board, and a health board has a population of somewhere between 400,000 and 600,000. And if we benchmark that against English services, we are low in procedure rooms and staff. So, we've come from a situation where we have a lower relative capacity for our procedures, both the rooms and the numbers coming through. Some data from England has suggested very recently, from last year, that you need to have about three and a half procedure rooms per 100,000 population over the age of 50. So, if you map that through, our six or seven rooms is actually low, so we need to increase our capacity. We need to have more, robust, flexible capacity that can be used, I think, outside health board barriers as well, where possible—so, regional availability.

Clearly, the pandemic's had a deleterious effect, but we were struggling with our waiting times even before that started, and health boards have used, as you say, extensively used, insourcing and outsourcing as a short-term way to help improve the situation, and it clearly has improved some of the capacity and some of the activity. But I think everybody I know—. And certainly my own personal mindset is that should not be a long-term solution; we need to build up capacity and we have to do that by, I think, increasing physical capacity—and there are different models that you could choose for that—and also the operators to work within that and all the support staff that you need.

Diolch. Do you want to come in there as well?

Yes. I completely agree with John's comments, and I think, alongside that, it's looking at pathways, clinical pathways, so that we can manage the demand coming into the system. And we've got lots of information around demand and capacity. I suppose, the resource that we're using currently, we need to use that as effectively as possible and look at productivity and our throughput and really look at and scrutinise all areas of the service, alongside forming that medium- to long-term plan as well.

Dr Jarvis, some thoughts?

Yes. I agree wholeheartedly with what my colleagues say. I think it's very important that there is a good workable model for every service as to what demand and capacity is likely to be. As a general rule, I suppose, it sounds like there isn't enough and the amount that you will require will probably increase by perhaps 10 per cent every year. But there are things that can be done to mitigate this, and I think every service should have a short-, medium- and long-term plan in order to deal with capacity, and certainly that's in keeping with the JAG model. It's amazing, actually, when services are coming up to accreditation, or passed accreditation and awaiting re-accreditation, how that really focuses their minds and allows them to overcome some of the capacity issues. We do at JAG require, for accreditation, that, in terms of waiting and capacity, there is a plan and a trajectory, rather than absolutely everything having been achieved at this stage in terms of capacity and performance. So, there is a little bit of wriggle room in terms of JAG accreditation.

But the sorts of things that might occur in a short-term plan would be that waiting lists are booked—[Inaudible.] It's an obvious thing, but it's something that really can make a difference for services. Insourcing and outsourcing: yes, it's a short-term plan, but actually, in England, many services, my own included, have been doing both of those for 10 years and are still having capacity issues. So, I think pinch of salt—yes, it is something we'd like to get rid of, but, in a way, we may be stuck with it for a while. There have been alterations recently in referral guidelines and in vetting, in particular of BSG colon surveillance guidelines, and actually incorporating those will allow us to do fewer colonoscopies, as long as we do it properly.

In the medium term, it's to do with maximising list utilisation, and we've talked about cross-cover for consultants, perhaps evening work and training nurse endoscopists. And in the long term, there really must be a robust plan for infrastructure and staffing—make plans as to what's required and come up with a credible plan to make that happen. It's the same throughout the whole of the UK and beyond in terms of volume and capacity. It's an important topic and it sounds like there have been some good inroads within Wales to doing this, and you should be encouraged to be congratulated on this. But the delivery does remain a problem, and it's likely to remain a problem because you're starting off from a position of being behind in terms of what you can deliver, and it's likely to be accelerating away in terms of the amount of endoscopy that you need to provide with those roughly 10 per cent figures of increase every year.

Thank you very much for the answers from the three of you. I think there's real consistency there that's really useful to us. I'd add, perhaps, that you're starting from a position also where a lot of your resource capacity, money, is going into paying for the insourcing and outsourcing, and Professor Dolwani said, when he was giving evidence, that an absolutely staggering amount of money was going into those kinds of contracts. Is the big challenge, as we set off on that trajectory that we heard mentioned there, to transition, and to transition at a time when that money's locked up in insourcing and outsourcing contracts?

That is the challenge, isn't it? And I think there's going to have to be a lead-in time before you can realise the increased capacity that we need. It takes a while to build the rooms and it takes a while to train the staff and to bring them in, so there has to be almost like a sliding scale sort of change, I think, really, from that way. But, yes, the amount of money that's been spent is large, and, clearly, I think everybody would agree that's better invested in a sustainable, robust, long-term solution rather than the short-term aspect. But it has delivered endoscopy, which has been helpful to manage patient care in the shorter term. So, I can see why it has been done.

The second area I wanted to look at, you've referred to it—

Can I just—

Yes, sorry.

—say one more thing? So, in terms of a plan to address capacity, a part of that has to be commitment to training, and training actually reduces capacity while it's being done. So, a 12-point list, if it becomes a training list, it's likely to be an eight-point list. So, we need to have commitment to training in accordance with predicted needs in the future, and we have to bite the bullet in terms of what that's going to do with capacity in the short term, and perhaps some ongoing commitment from insource and outsource would be the way that we do that.

That's a very good point.

The second area was on the need to move away from silo working, something that you've already referred to this morning. Do you, Dr Turner or Dr Jarvis, have anything to add on the theme of working across regions, using resources more efficiently by co-operation and so on?

I'm sorry, we'll just have to have slightly shorter answers so we can get through all our questions, but sorry to ask for that.

I think there are benefits, both in working collaboratively in terms of your pathways, so you've got very streamlined pathways, but also again in terms of workforce. If you're combining, I suppose, your administrative workforce, for instance, in a regional centre, you know there are potential benefits as to the number of resources you need for that, if you're working across different health boards.

Dr Jarvis, did you have anything specific to add on that?

Nothing to add there.

Okay. And finally from me, we need to increase capacity—we can see that—and work is being done on developing regional diagnostic centres, possibly moving towards even community diagnostic centres, though we have had some concerns voiced to us about whether that is necessarily the safest way to operate. What are your thoughts on those kinds of diagnostic centres being developed along those models?

I think having regional centres, potentially, where you can co-locate imaging plus endoscopy and different areas, has benefits from the patient point of view, if you have an endoscopy and we suspect a patient's got cancer, where they can have their CT scan and other tests done on the same day—so, in terms of travelling. I think in a community setting, for endoscopy, it's probably got less of a role for our core endoscopy procedures, because you need all the infrastructure, like decontamination and things like that. But there are innovations around endoscopy that could be delivered in more of a community setting, like cytosponge and probably some of the other innovations that you may have heard about.

Dr Green.

Very quickly, I think it's recognised that you can do a number of endoscopy procedures in a community-type setting. I've certainly peer reviewed a number of English settings where things have been done in general practice settings, and very rural, but you have to have clear pathways and processes, and also, critically, have the right patient selection for how ill or well they are, and what you're doing in terms of being a diagnostic rather than therapeutic. So, I think, with patient selection, it is very much possible to do things outside the traditional hospital models.

Okay. Thanks. Dr Jarvis.

I agree. I agree, community endoscopy is very reasonable, it's very safe if it's properly done and the correct patients are selected. So, I have no real reservations, as long as it's done properly, that that's a safe and appropriate thing to do. We have many of them in England.

Okay. Thank you.

Thank you. Jack Sargeant.

Thanks, Chair. If I can just go back to the response from Dr Green to my colleague Sarah Murphy earlier, you spoke about working across health boards, and essentially said it's pretty tricky to do, but it is doable, and improvements can be made. What are those improvements? What can this committee say to get those improvements in that area?

I think some of this probably goes beyond the world of endoscopy. I think it goes to how we organise and deliver HR processes and contracts. For example, outside the world of endoscopy, there are certain clinic skills that are recognised that somebody can do in one health board. As a nurse, they move to another health board and have to have the training again, and things like that, which seems a little bit not necessary. I do some endoscopy at the weekends, helping to support people who want to be bowel cancer screeners, and I have to have like an honorary contract in the health board that I'm going to to do things. It's doable but it probably could be easier. For trainees, trainees tend to be located in the health board they're in at the moment, don't they?

Yes. They can work more flexibly generally across health boards at a training level, but I agree with John's comments that, if you've almost got an all-Wales contract, so you can move seamlessly between health boards, that would be of great benefit.

Okay. That's very useful. I think it goes back to the point about making sure that we have that data so we know exactly what we've got. Thank you for that.

In terms of nursing work—

Sorry. Mark.

In terms of nursing workforce, there is some training that is universal that's a JAG-related thing. The JETS Workforce training for those assisting in endoscopy, it is an universally accepted training module, which might help if some of your assistant staff want to work across boards. It may be that that's helpful for you.

Thank you, Dr Jarvis. If I can just—. I'm conscious of time, but if I can take you away from that to where I originally was going to go, in the last session, we heard evidence from Professor Dolwani, and he said that it had been clear for some time that the solutions to improve endoscopy services were there, they've remained the same for a number of years before COVID, and the quote that we have from him is he described the pace of change as, and I quote, 'incredibly slow'. Do the witnesses, and I look to the three of you, share the view of Professor Dolwani? I don't who wants to go—.

Who wants to indicate? Dr Green.

So, I understand the challenges of making change. It is always challenging. The national endoscopy programme has set a number of—. By the work it has done, it has found optimal ways of doing things and has encouraged things like services going through to JAG accreditation, but it's not a delivery—it's a nationally directed body. And I think it's something that—. I may be incorrect, but I hope that with the new changes, with the new NHS executive, et cetera, there may be some—. It may help to facilitate the process of things that are felt to be good things to happen, versus the health board and their pressures that they have to deliver lots of different things. So, I think it's—. I understand what he said and I can see it from my own experience as well, that there is often a delay, or a time frame, before things happen that I think everybody agrees are the right things to happen, as it were, but there are the real-world pressures, of course, so—.

Just before I bring Dr Turner in to respond on this, would you say, Dr Green, that the new or going-to-be-established NHS exec should be responsible for change, rather than health boards?

That's a really good question, isn't it? I have read a number of documents relating to the new structure, and obviously until it happens I don't quite know how that's going to function and be working, but I think a body that brings things together that involves the execs and chief executives has got to be potentially a helpful philosophy to engender change across the country, yes.

Thank you, Dr Green. That's useful. Dr Turner, you wanted to—.

I also—. There are examples of it, but opportunity to set up a broader community of practice. There's loads of great practice happening in health boards, and it's sharing that knowledge so that you don't necessarily need to reinvent the wheel, share different ways of working, innovations, and I think that would have benefit as well.

Because we talk about this often in pretty much every session we have for various things, we find that's pretty tricky. The evidence we've heard is that, again, there are barriers in place. Is there a simple solution to remove those barriers?

I think there are people from different areas of the workforce that are very enthusiastic about change, and I think it's just providing a vehicle to bring those people together as a community to discuss what's happening in different areas, and, as I said, share that learning and see how you can spread and scale it then.

Okay, thank you. I'm conscious of time, Chair. That was very useful.

Thank you, Jack. Joyce Watson.

I think if we let Gareth go, in case we run out of time, because he particularly wants to ask—and mine's been part answered.

I'm very grateful, Joyce. Gareth.

Thank you, Joyce. Thank you, Chair. I want to ask about Lynch syndrome. I think it's 25, isn't it, that they start the monitoring process? Is 25 right? Do you think 25 is the right age, or do you think it could be possibly sooner, to capture those people in the system?

I think we currently base it—. We've got European guidelines that have been adopted by a national body—the British Society of Gastroenterology. It's based upon, I suppose, evidence-based guidelines that suggest that the risk of colorectal cancer below the age of 25 is very low. So, they've used that as the starting point. But often, people with Lynch syndrome are supported and are reviewed by genetics services, with counselling. So, some of the advice that's given may be individualised as well, depending upon that individual person and their personal history and family history. So, that's the current guidance, but if there are other bits of information that suggest that we ought to work outside that guidance, then the genetics service or clinicians with an interest in that field may give slightly different advice.

And just to touch on this wraparound care that's around people who've been, especially, newly diagnosed with Lynch syndrome—. Because if you're in your early to mid 20s, it's a bit of a blow, isn't it, if you've been diagnosed with a genetic condition that could result in bowel cancer? So, what's the wraparound care, in terms of social services, mental health support, that could be around? Are they offered that at the time of diagnosis, or is it something that's a bit secondary to that diagnosis?

So, again, the patients who present will present through a whole different range. There may be somebody with a cancer where there are really good support services across the country for it—specialist nursing, et cetera, who provide a lot of mental health counselling support to newly diagnosed patients with Lynch, and what have you. The ones who come through for part of their counselling is mental health support when they come through the genetic counselling services. So, I think that is very much built into it, and there are lots of good published resources to support patients as well. So, yes, it would inherently be part of the counselling and support processes initially for Lynch patients, yes.

And is there specific support around support for women, in particular, of child-bearing age? Because if it's early 20s, mid 20s, then is there specific women's support around those diagnoses?

I can't give you an exact answer on that, to be honest. The best person to address that would be through the genetics-type team, who see the people, but they would include a holistic support to the person beyond the bowel cancer, because obviously they have other malignancies that they're prone to as well. So, yes, I'm sure that it would be wrapped in those services when they're seen.

Okay. I just think it's important to specify on that, to make sure that nobody slips through the net, in that sense.

Yes, absolutely.

With the polyps, if they are screened at the time of an examination, are they removed at the time of examination, or do they have to have a secondary appointment in order to get them removed?

The majority of—. Both of us do colonoscopy, and Mark does as well. When we see patients who come through, there's a recognised—the majority of polyps that we see, we'll remove at the time of the index procedure, the first procedure they come through. But we all have guidelines in place for certain-sized polyps, or certain patients as well, with other risk factors, like taking blood thinners and things, where you wouldn't do it on the first procedure. And we've also built in good multidisciplinary-team approaches, where we can take videos, and discuss the optimal management of patients, whether it be another endoscopy procedure or surgery, depending on what we find at the time. So, yes, the majority, there's a recognised safe limit of polyps that can be removed; the bigger ones have a higher risk involved with removing them, and, sometimes, patients need to be counselled that way, and also, sometimes, that's not the right thing to do; it's sometimes better to do another approach to remove them. So, yes, there's guidance around it.

And just as a final question, if we are to raise awareness about this, are there enough people in the genetics industry to tackle the demand of potential increases in awareness of Lynch syndrome? Because I can fully appreciate that it's a very specific role and it requires a lot of training, so are there are enough people in genetics in order to meet that demand, if we were to raise more awareness about it?

Neither of us actually work within the genetics department, so it'd be difficult to give you a very informed discussion about that, but I know that our services—we've got one of the world-leading services, actually, in Cardiff, for genomics and genetics, and they've done amazing world-leading work, actually. So, I guess the answer probably would be that there was always need for more staff to see people earlier and support them, as—. Whatever the question is, that's often the answer, isn't it? But, yes, I suspect that more support and resources would be appreciated, but I think we have to acknowledge the high-quality care that patients do get in Wales with genetic disorders.

Thanks. Any comments from Dr Jarvis?

No.

No. Okay. Thank you very much.

Thank you, Gareth. Joyce Watson.

I'll come back now; I wanted to give time for that because it was important. Innovation, I'm going to talk about innovation, and we've had evidence that says that Wales can be comparatively slow to adopt innovation. And is innovation always useful? You touched on it earlier—I think it was Dr Green—when you said that the use of some innovative technologies might not necessarily suit the patient. So, I want to know how we can use that innovation, why we're not using it and where it would be appropriate.

I think I agree that there can sometimes be multiple steps that you need to go through to get things over the line in terms of introducing new innovation. There are examples in Wales as part of the national endoscopy programme, so things like colon capsule, which provides an alternative for patients, and I think also equity of care for patients. We've had some people who haven't been able to undertake standard endoscopy or CT scans, so that's been really positive. There are other innovations, so things like trans-nasal endoscopy and cytosponge we mentioned earlier. I think it's important to support innovation because, again, it helps with your recruitment to endoscopy services, when people come into a service where they know that there is opportunity to be involved with innovation throughout Wales. I think innovation's got a role, but in terms of managing endoscopy backlog and demand, it's probably got a limited role.

Okay. Thank you.

I'd very much agree with that. I think there are pockets of examples across Wales of colleagues who are doing research and piloting work, piloting all of the things that you've mentioned, and other things like artificial intelligence in endoscopy—there are clinical trials going on with that at the moment. The FIT in primary care work, in symptomatic population, was done through a careful analysis before it was rolled out. I think I'd just reiterate the point that these innovative practices are all good, but I would go back to my point earlier that they are supplementary to the gold standard core work of endoscopy, which I think we do need to make sure that we are meeting the needs for. So, yes, very much a supporter of innovation, but I think it does need to be put in the context of the fact that we need to ensure that we are doing enough of the standard gastrointestinal endoscopy, which is the optimal way of imaging and treating patients at present.

Dr Turner.

Jarvis.

Dr Jarvis.

Oh, Jarvis. Sorry—I'm never good with names.

Yes, I agree. Innovation is important but it's only got a relatively small role. Things like cytosponge and colon capsules, yes, but we mustn't be distracted from the fact that we do need to be doing more endoscopy. It's kind of innovation, but things like tightening our criteria and making sure that we obey those for referral of procedures will decrease the number of procedures that we need to do, and using FIT testing to limit the number of colonoscopies is also an important area, which is kind of an innovation. It's something that we should be doing, in keeping with BSG guidelines.

Okay, thank you. Thank you, Joyce. There's obviously an important role in terms of the endoscopy service with regard to the treatment of non-cancer conditions, and I just wanted a view from you all, really, in terms of whether you believe that that's adequately reflected in Welsh Government policy and funding decisions. Dr Green.

I'll go first. I'm grateful for that question, because I think we have to all reflect how important endoscopy is as a vehicle for assessing patients with potential cancer; preventing them from having cancer by removing polyps, which are pre-malignant conditions; and also treating cancer—we can do a number of treatments to palliate and improve the survival of somebody. But actually, it's only a proportion of our work, and the majority of our work is actually done in people with symptoms where cancer is a very low possibility. Those patients deserve the opportunity to have their symptoms adequately explored, because the conditions they have can provide huge amounts of morbidity and affect their well-being and their quality of life, et cetera. I do think it's important to remember all that.

Also, critically, endoscopy is also an emergency service, so the three of us—Mark, myself and Jeff—will be on call for patients with bleeding, and we get called in at some ungodly hours to come in and sort people out who are bleeding. So, I think it's really important to remember that cancer is a very important focus, and there is a huge—and very correctly so—focus on that nationally, but that's again why I go down to my point I made earlier on how important it is to go through accreditation processes with JAG, who look at the whole, holistic service that's delivered of endoscopy, not just to focus on malignancy. So, it's right that we have targets. It's right that we have a focus on cancer. But we have to ensure that the whole population who have symptoms are adequately assessed and explored, and I think that's—. Yes.

I was going to ask, do you think that that's adequately reflected in terms of Welsh Government thinking and funding?

I think it's there. I think the cancer thing always sort of grabs the limelight a little bit, because it's obviously rightly a big focus, but I do think we have to remember that what we do is far beyond that as well. I think pushing things like the accreditation process and making sure that all patients don't wait too long for their procedures, not just the ones at the front end, is really important.

Yes, Dr Turner.

It was just to complement; I completely agree with what John has just said. We've got symptomatic patients but also people, like with Lynch syndrome, who are on the surveillance pathway as well, and it's really important that we perform endoscopy for things like Barrett's oesophagus, and people with liver disease, to look for dilated veins in their gullet as well. So, it's really important that the surveillance group of patients that may not have symptoms is factored into the planning of endoscopy services as well.

Okay, thank you. Dr Jarvis, if you wanted to come in.

Yes. Little to add, really. I agree with everything that John says. In order to get accreditation, one does need to have the waits at the appropriate time for surveillance for diagnostic and for potential cancer work.

Thank you. This is my last question before we finish. You're the professionals. We're the laypeople understanding and grappling with some of these issues. Are there any, perhaps, key messages or priorities that you think that we should be aware of? I'm not asking you to repeat anything you've said, but anything that perhaps you'd like to leave us with that's not already been said or mentioned.

Probably just to emphasise the benefit of training academies for endoscopy in terms of accelerated training, you know, across all workforce areas, and that facilitates people being accredited at an earlier stage to then being able to deliver service and support some of the gaps in the service and the expansion that we've mentioned. And again, just to ensure that we optimise what we're doing currently, both in terms of pathway work, but also productivity as well, alongside the planning to expand our capacity.

Okay, thank you. Dr Green.

I've mentioned my feelings around capacity and my plea for all Welsh services to go forward for JAG accreditation, which I think is a really empowering and supportive process; having been on both ends of that process, it really is. And the wide scope of endoscopy—. I guess the one thing that wasn't in this session but was covered elsewhere is screening, and the three of us would be huge advocates for the expansion of screening, as planned. It has been done in a very careful, planned and sensible way, and we all commend the roll-out for the next two years and hope we can be even more ambitious than the plans in Wales, because if we can drop the threshold down even further, then we will create more benefits for our population as well.

It's an obvious answer to this question, I think, but what are the barriers to being able to drop the threshold?

It's capacity. We've mentioned how we're constrained with rooms and operators, and there is a plan to look at those things and to develop more space for people. I think the way that it has been done has meant it has been carefully and correctly implemented over the last few years. I'm a screener, and I know from personal experience how beneficial it is for the people I treat. I'm a massive advocate of that planned expansion. And also I'll be in the age group where I'll be invited now, soon, as well. So, from a personal perspective, it's also a very good thing.

Yes, absolutely. Thank you. That's helpful. Dr Jarvis.

I think one other thing that I'd like to see is that every hospital or provider has a leadership team that is defined and that they have defined roles within them—so, they have a clinical lead, a training lead, a nurse lead and a management lead, all with defined roles and with time set aside for trying to get JAG accreditation. It's a process that, for a well-oiled, well-organised hospital, can take these people perhaps half a day a week for up to a year in order to get accreditation. These people need to be supported by those above them, and when they highlight a problem, it needs to be listened to and actioned. That would be my advice.

So, the hospital structure at the moment doesn't have that leadership set-up that you've mentioned.

Well, everyone should. If you're to get accreditation, that must be in place. I'm afraid I'm not sure if every hospital has one. But when my colleague Debbie was looking around, it was felt that, perhaps, those teams were either not in place or not given sufficient time to do the work that they needed to, or not given support when there were problems.

Why wouldn't they be in place?

Why wouldn't they be?

I suppose I'm asking you to speculate why in a hospital that structure wouldn't be in place.

Perhaps difficulty recruiting those individuals, if they have a lot of competing pressures, or they've got the role and no time is set aside in order to do it. So, that's a job planning issue. Or perhaps they're just not supported from above.

I guessed that would be your answer, I just wanted to draw that out. That's really helpful. Thank you. Dr Jarvis, Dr Green, Dr Turner, we appreciate you're all really busy, so we really appreciate your time coming to committee this morning. That's very helpful in terms of helping us in our last session on endoscopy services. Diolch yn fawr iawn.