About this document | Introduction | Groups of learners | Challenges to re-introduction of training| Prioritising access to training | Alternative training resources | Modification of certification pathways | Novel models of endoscopy training in the future | Resources | Further information 

Published 8 June 2020 

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About this document

This document provides guidance for the recovery of training in gastrointestinal endoscopy following the COVID-19 pandemic. Restoration of services will vary significantly and so this guidance provides points for consideration and application locally.  

This guidance should be reviewed alongside the advice on recovery collated on the JAG website as well as guidance from government, professional societies and other agencies. Links to several resources are provided at the end of this document.  

This guidance is likely to change regularly; please refer to the JAG website at www.thejag.org.uk/COVID-19 for the latest version.

Introduction

• Elective and screening GI endoscopy services have been significantly impacted by the Covid-19 pandemic, due to the high risk nature of the procedures to staff, availability of personal protective equipment (PPE) and the need to deploy staff and equipment to alternative services. As a result, training in endoscopic procedures has been effectively halted.

• High quality training of the future endoscopy workforce should be restarted as soon as practically and safely possible

• As endoscopy services are reinstated, an approach to the prioritisation of training to different groups will need to be considered based on training, service and workforce needs.

• The reintroduction of training is likely to be impacted on by several factors including the accumulated backlog of diagnostic and screening work, availability of PPE and the availability of training staff. The need for PPE, notably for pre-tested patients undergoing lower GI procedures is under review and this would provide an opportunity to restart training.

• The training centres that provide JAG approved training courses (including basic skills in endoscopy courses) have stated that patient focused courses will resume in September 2020 at the earliest.

• This document outlines possible approaches to the prioritisation of learners and the opportunities to review how we train in endoscopy going forward.

Groups of learners​

The table below identifies the key groups of endoscopy learners and details relating to their training. 

HEE clinical endoscopist programme: Staff on secondment to this programme for upper GI endoscopy or flexible sigmoidoscopy have a time limitation on training (7 months). A pilot to deliver colonoscopy training has been delayed due to Covid-19. Key workforce development for symptomatic service provision and bowelscope screening provision and potentially as screening colonoscopists in the future.  

Degree based ‘nurse endoscopist’ programmes: on BSc or MSc based programmes. Key workforce development for symptomatic service provision and bowelscope screening provision and potentially as screening colonoscopists in the future.  

Gastroenterology Specialist Trainee: Key workforce development for symptomatic service provision and potentially as screening colonoscopists in the future. Usually training in conjunction with other aspects of specialty.  

Paediatric Gastroenterology Specialist Trainee: Key workforce development for symptomatic paediatric service provision. Usually training in conjunction with other aspects of specialty.  

GI surgical Specialist Trainee: Will provide symptomatic service provision and some may potentially train as screening colonoscopists in the future. Usually training in conjunction with other aspects of specialty.  

 Other staff: eg specialty and associate specialist doctors, previously appointed consultants learning new techniques​.

Challenges to re-introduction of training  

There are a number of challenges for services to restart endoscopy training, as well as considering the wider challenge of restarting endoscopy services. These are outlined below.   

Service pressures: Need to deliver endoscopy as efficiently as possible, so reducing number of patients on lists to allow for training will be challenging.  

Provision of personal protective equipment (PPE): Supply of PPE is limited so the need to provide an additional individual with PPE may be challenging. It is likely that these requirements will reduce as pre-testing or preemptive self-isolation of elective patients is introduced, and we would encourage units to allow trainees into the endoscopy environment as soon as it is appropriate to do so. 

Deployment of learners into other areas: Several endoscopy learners will have been redeployed to other areas to cover Covid-19 associated rotas and may not be able to return to endoscopy. 

Procedure type: Majority of procedures being carried out will be urgent / therapeutic procedures that are not appropriate for training. 
Level of personal risk of the learner: Learner, or others involved in delivering training, may wish to avoid potential exposure to Covid-19. 

Prioritising access to training 

Given these challenges, provision of training will need to be prioritised. The following principles should be considered:

• Time pressure to complete training for an individual learner

• Point at which a learner will complete training and therefore join the workforce

• Volume of predicted service delivery by the learner

• Availability of training across a service network

• Availability of specific training within the service framework (eg in the setting of an emergency endoscopy, ERCP).

The prioritisation of training should be carried out on the basis of the below: 

• Definite availability for the training session for the learner

• Appropriate procedures being carried out to meet the learning needs

• Sign off requirement for progression/completion of programme (priority should be based on time left to end of programme and include consideration of any extension to training agreed by the programme organiser. 

• Likely contribution of the learner to the service post certification 

 The following considerations should be taken into account with regard to which procedures to offer training:

• With the workforce demand for lower GI endoscopy, and the need to support delivery of a cancer diagnostics and screening, prioritisation of colonoscopy training should be considered over upper GI endoscopy training

• This position is further supported by the high risk nature of upper GI endoscopy with respect to Covid-19 aerosolisation

• The delivery of training on therapeutic procedures and the management of acute intestinal bleeding should be promoted given these skills will be required by those approaching the end of training, so as to ensure that completion of programmes is not delayed due to lack of development of therapeutic skills. 

 It will remain with the departmental service and unit training lead to determine, on an individual basis, the prioritisation of learners to access endoscopy training. ​

Alternative training resources 

In the face of the challenges outlined above in restarting patient-based GI endoscopy training, we would encourage the use of other learning resources and opportunities, and the consideration of different programme delivery models including: 

• completion of e-learning (for example e-learning for Health endoscopy modules) (www.e-lfh.org.uk/programmes/endoscopy/ or www.eintegrity.org/e-learninghealthcare-course/endoscopy.html if not working within the NHS)

• accessing other e-learning resources (for example www.esge.com/elearning/, https://learn.asge.org/Public/Catalog/Home.aspx, www.rcplondon.ac.uk/educationpractice/courses/ www.rcseng.ac.uk/education-and-exams/courses/rcs-elearning/ or https://rcnilearning.com/)

• use of model based training with a supervisor

• use of endoscopy simulator-based training where these are available

• supervision over video for learners close to sign off to reduce PPE use and the number of individuals in a procedure room where video links are in place

• regional or nationally delivered technology enhanced programmes (eg in pathology recognition, case management) and live procedure broadcasts based on the ‘EndoLive’ model. 

Modification of certification pathways 

We do not, at this stage, propose to modify the certification pathways that are in place, as they are designed to ensure safe, high quality, endoscopist practice. There is a concern, however that training ‘momentum’ will have been lost and therefore that there may have been a drop off in skills. We have amended the time period relating to certification as follows: 

• A minimum of 15 procedures are carried out in 6 months prior to certification 

• That 5 of those procedures have been carried in the 6 weeks prior to application 

• That the summative DOPS have been carried out in that 6-week period

Novel models of endoscopy training in the future

There is an appetite from trainers and trainees to identify new models of endoscopy training.  As a result of this and to take the opportunity of the challenges that we face, we are progressing with plans to work with training units and statutory bodies across the four nations to develop models that could include: 

• Creating ring fenced endoscopy placements within specialty training programmes.

• Reviewing basic skills course delivery to assess e-learning components and the learning objectives to ensure they are of value.

• Considering other systems of training delivery such as regional academy models. 

JAG will continue to work with stakeholders and partners to support the provision of a high quality endoscopy workforce. 

Resources 

The following resources support this guidance. These resources are likely to change and should be checked regularly. JAG have collated Covid-19 information on our website - https://www.thejag.org.uk/COVID-19. 

• 1: Guidance on recommencing gastrointestinal endoscopy in the deceleration and early recovery phases of Covid-19 pandemic https://www.bsg.org.uk/covid-19-advice/bsg-guidance-on-recommencing-gi-endoscopyin-the-deceleration-early-recovery-phases-of-the-covid-19-pandemic/ (accessed 30 April 2020).

• 2: Service Recovery Documents: The What, When and How. https://www.bsg.org.uk/covid-19-advice/service-recovery-documents-the-what-whenand-how/ (accessed 30 April 2020).

• 3: Reducing the risk of transmission of COVID-19 in the hospital setting. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infectionprevention-and-control/reducing-the-risk-of-transmission-of-covid-19-in-the-hospitalsetting (accessed 30 April 2020).

• 4: HTM 07-01 Guidance on the safe management of health care waste.  https://www.gov.uk/government/publications/guidance-on-the-safe-management-ofhealthcare-waste  (accessed 30 April 2020).

• 5: Clinical Guide for the management of essential cancer surgery in adults during the COVID-19 pandemic.  https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/C0239Specialty-guide-Essential-Cancer-surgery-and-coronavirus-v1-70420.pdf (accessed 30 April 2020).

• 6: HTM 03 – 01 Heating and ventilation systems: Specialised ventilation for healthcare. https://www.gov.uk/government/publications/guidance-on-specialised-ventilation-forhealthcare-premises-parts-a-and-b 

• COVID-19 (COVID-19) Clinical guidance for managing patients

• https://www.gov.scot/publications/COVID-19-covid-19-clinical-advice/

• COVID-19 (COVID -19) Guidance documents.

• https://www.gov.scot/collections/COVID-19-covid-19-guidance/ 

• Leading Wales out of the COVID-19 pandemic: A framework for recovery.

• https://gov.wales/leading-wales-out-COVID-19-pandemic 

• COVID-19 (COVID- 19) Overview and Advice.

• https://www.nidirect.gov.uk/articles/COVID-19-covid-19-overview-and-advice  ​

Further information

For further information, please see www.thejag.org.uk/support. ​