Cheshire and Merseyside endoscopy network is a group of eight endoscopy services across 12 sites, led by Dr Neil Haslam and Dr Ash Bassi. This new network aims to standardise practice and reduce unwarranted variation to make better use of resources and improve patient outcomes.

We spoke to Neil Haslam and Karen Lloyd, endoscopy improvement project manager, about how teamwork and a mindset of ‘no trust left behind’ starts with putting the patient first. Member endoscopy sites have commented on the assurance that the network has given them to participate in initiatives knowing that they have the support of the network management and can call on neighbouring Trusts to share their experiences.

 

Improving efficiency

Once the network had formed, an exercise was undertaken across all sites to understand capacity, demand and productivity, and to ensure that all units maximised the resources available. The network estimated that they could increase capacity by 20% through implementing productivity measures and implemented an action plan to support this. Trusts are now aiming to fully book every list and are harmonising the points per list to the recommended 12 points wherever possible.

 

The network developed and implemented strategies to control demand and fully utilise capacity. A standard set of points per procedure was agreed and a web-based tool to measure room efficiency was implemented. Standardised pathways were developed for lower and upper gastrointestinal (GI) 2-week wait patients to stream and vet patients. Productivity tools were also developed to examine utilisation of endoscopy lists, room turnaround times, the number of points booked and achieved on a list, and did not attend (DNA) and cancellation rates.

The network has seen improvements in turnaround time, room efficiency and reduced DNA rates. They’ll be rerunning the demand and capacity exercise in the future to measure their improvement so far and to identify further areas for improvement.

Procuring equipment
Services in the network worked together to procure equipment as a single body to leverage their buying power. At first, endoscopy accessories such as snares and injection needles were procured. An Endoscopy Network Procurement Group was set up which provided a forum for the Procurement Leads in each Trust to get together to discuss the progress of trials and how to overcome barriers to change.

 

 ‘Over a 12 month period, the network made a saving of £278,000 recurrently per annum and this has been reinvested back into our services.’  

 

They started with common inexpensive items such as biopsy forceps. The next step with this workstream is to procure more expensive and specialist items, such as endoscopes and stents. It is estimated that the network could make savings of up to £1.4M per annum.

 

Implementing the new post-colonoscopy surveillance guidelines
The network planned to implement the new surveillance guidelines and found that the COVID-19 pandemic gave an opportunity to continue this work. Despite the redeployment of most endoscopy teams, trusts reviewed records of patients who were due for surveillance in the next 5 years. The network initially focused on lower GI patients before beginning to review patients with Barrett’s oesophagus. While the task was significant, with more than 21,000 patients to be reviewed, they managed to review more than 7,000 records and appropriately discharged more than 3,500 patients.

 

‘We’re continuing to review our patients, albeit at a slower rate, and are committed to reviewing all patients in the coming months.’

 

Trusts also worked with their genetics clinics to undertake a one-off vetting of patients undergoing surveillance because of a family history of colorectal cancer. The aim of this was to ensure that patients were on the correct surveillance schedule. Around 1,000 patients were validated and removed from the waiting list (around 20%) and other patients had the frequency of surveillance increased.

 

New configuration post COVID-19
The COVID-19 pandemic meant that although the network’s plans had to change, the work so far has enabled them to respond effectively. Work continued to ensure that emergency endoscopy still went ahead for patients who required it. Each trust established how many patients they had on each waiting list and prioritisation was set on who needed to be seen first. Faecal immunochemical test (FIT) testing was developed rapidly and implemented across the network so that every 2-week pathway patient was tested to establish their priority for endoscopy. This led to an agreement of working together – ‘no trust would be left behind’. 

‘The extent of backlog is significant, but we consider this to be a network backlog and we will clear it together.’

 

 

‘After weeks of anxiety patients will see the consultant they expected to see, albeit in different surroundings. For some this will be life changing.’

 

 The ability of one trust to go first when dealing with COVID-19 meant that they could share learning, and others could then move quickly and seamlessly through the process. Trusts are committed to ensuring that if a patient needs a procedure and there is a slot available on a list, they will dispense with trust boundaries and see the patient. Consultants work collaboratively to share lists and provide endoscopy for each other’s patients.   The Bowel Cancer Screening Programme where the first to introduce this and have had success in pooling the lists.  Currently the arrangement is that whichever Trust is able to will supply the consultant, and whichever Trust can, will supply the endoscopy theatre.  The patients are on a pooled list and offered the slots in order of clinical need and no cross charging will be undertaken.  There is an understanding that Trusts will deliver this fairly with each Trust providing a share of resource now or in the future when they are better placed to do so. 

 

Other improvements
The network implemented a validated training programme for the administrative workforce which led to savings. They’ve also produced a standardised electronic patient feedback tool which has enabled more patient involvement. Current feedback rate for this standardised tool is 11%.

What’s next?
The network continues to consider ways to achieve their aims with future developments in motion. There’s work underway to create a virtual capsule network to share expertise across a large geographical area. This will mean that a procedure can be undertaken in a unit local to the patient and results analysed in a capsule endoscopy hub. 
In addition, a referral management system will be rolled out to vet referrals. This will use a standardised methodology to increase adherence to referral criteria and indications, helping to ensure that the right procedures are undertaken on the right patients and reduce unnecessary demand.
Due to some of the units being small, a lot of staff have been redeployed elsewhere. The network knows that restaffing units after COVID-19 will be a challenging task, and these sites will require support. Each trust has committed to providing their daily situation report (SITREP) on a monthly basis so they can see who is struggling for capacity and where to direct support.

Advice for other services
Cheshire and Merseyside Cancer Alliance has provided central funding to enable this work to happen and it has been a strong source of support and a driver for change. The network recommends engaging your cancer alliance early on and involving them throughout.
The network’s ethos of communication, collaboration and moving forward together has been paramount. There have been challenges at times in agreeing the best solution, for example agreeing a colorectal and 2-week wait pathway. Careful listening and negotiation have meant that effective solutions which work for all units were implemented.

Standardisation has been a strong theme and important to the network’s success. This has covered everything from referral pathways and vetting criteria to patient feedback and infection control measures. This has reduced variation and enabled colleagues to work together more effectively.

‘The hard work by all our staff has meant that as a network we have moved forward together under our guiding principles of putting patients first and ensuring no trust is left behind. We have a lot more ideas and initiatives to come and are proud of our achievements so far in improving the quality of care for our endoscopy patients.’

 

Resources available to share on request:
• Pilot around genetic review
• Paper on pre-assessment and on surveillance vetting