Endoscopy and urology diagnostic: recovery and renewal plan

Key Areas – Balancing Demand and Capacity

Optimised Patient Access – We will improve access for patients and minimise waiting time variation for a diagnostic test. To reduce the waiting time, promote the effective use of existing capacity and to support the recovery and renewal of endoscopy and urology diagnostic service.

• Increase and co-ordinate capacity across NHS Scotland utilising all additional capacity.
• Increase the effective use of our existing capacity by reducing unwarranted variation in practice to ensure efficient scheduling and booking.
• Develop and implement a national framework for the management of surveillance patients. This framework will provide clinically prioritised endoscopy access and will incorporate new technologies such as Quantitative Faecal Immunochemical Test (qFIT), Cytosponge^TM, and Colon Capsule (CCE) where these are clinically appropriate.
• Support redesign to provide alternatives to traditional endoscopy and inform clinical prioritisation. This will include Capsule Colonoscopy Endoscopy (CCE), Computer Tomography (CT), Cytosponge^TM and Transnasal Endoscopy (TNE). For Urology, alternative delivery pathways such as Diagnostic Urology Hubs and 'One Stop' clinics.
• Develop modelling tool ensuring accurately capture and manage of fluctuating capacity and demand. We will strive to bridge the current capacity gap as we move towards sustainable services.

Key Areas – Optimising Clinical Pathways

Patient Optimised Care – We will develop and implement clinical pathways that optimise the value of endoscopy and urology diagnostics in each patient's care. In partnership with the Centre for Sustainable Delivery (CfSD). These revised pathways will also apply the principles of Realistic Medicine.

• Promote and implement 'Once for Scotland' pathways to prioritise demand for cystoscopy including:
  • Visible and Non-visible Haematuria
  • Recurrent Urinary Tract Infections in Males and Females
  • Non–invasive Muscle Bladder Cancer Surveillance
• Promote and implement guidelines for 'Once for Scotland' gastrointestinal pathways to prioritise endoscopy demand including:
  • qFIT validation and prioritisation of new and existing referrals
  • Upper gastrointestinal scoring prioritisation of new and existing referrals
  • A National Barrett's Oesophagus Surveillance Programme including the British Society of Gastroenterology Barretts investigation and surveillance guidelines
  • British Society of Gastroenterology guidelines for cancer and polyp surveillance
  • British Society of Gastroenterology for family history surveillance
  • Non-biopsy diagnosis for Coeliac Disease
  • Non-endoscopy diagnosis for Irritable Bowel Syndrome
• Develop new, clinically driven evidence based gastrointestinal pathways to safely reduce demand for endoscopy and improve outcomes. This will ensure every patient is on the correct clinical pathway, treated by the correct specialty in a timely manner. We will introduce national pathways for:
  • Iron Deficiency Anaemia
  • Non-endoscopic follow-up for uncomplicated diverticular disease
  • Non-endoscopy surveillance for compensated cirrhosis
  • Inflammatory Bowel Disease Surveillance
  • Endoscopy optimised upper GI ulcer review

Key Areas – Improving Quality and Efficiency

Optimised Patient Experience – We will improve patient experience by working in partnership with patients to deliver quality endoscopy and urology diagnostic services and provide appropriate and timely information. Implementing a quality framework that will inform best clinical practice, improve quality and drive efficiency.

The framework will cover all aspects of endoscopy and urology diagnostics including booking and scheduling, patient environment, patient information, endoscopy reporting and endoscopy quality. To ensure endoscopy and urology diagnostic services in Scotland are driven by quality and efficiency, we will:

• Develop audit and data collections tools to capture and monitor endoscopy and urology diagnostic performance and patient outcomes. We have commissioned a national post-colonoscopy cancer audit to assess the quality of colonoscopy in Scotland and national databases to capture clinical outcomes for Barrett's Oesophagus Surveillance, Non-muscle Invasive Bladder Cancer Surveillance.
• Implement a quality improvement framework to continue to drive quality and efficiency improvements. An independent review of quality and efficiency of endoscopy services has been commissioned to inform targeted improvements that will be taken forward by our clinical teams.
• Support a regional 'test of change' for the provision of an optimised bowel screening pathway that provide a 'one stop' model to improve patient experience and timely endoscopy and diagnostic delivery.
• Implement a National Endoscopy Reporting System to standardise endoscopy reporting and will provide accurate activity data, prospective endoscopy quality data and will provide support for endoscopy and urology training. The reporting system will also optimise to scheduling and booking efficiency.

Key Areas – Workforce Training and Development

Optimised Patient Outcomes – We will optimise patient outcomes through the programme of workforce training and development, improving access to diagnostics as we increase the skilled workforce. In collaboration with National Education Scotland (NES), the NHS Academy and the Centre for Sustainable Delivery, we will deliver a programme of training and development across the different elements of the endoscopy and urology diagnostic workforce. We will:

• Introduce a National Endoscopy Training Programme to provide training for all staff involved in the delivery of endoscopy in Scotland. A National faculty will deliver essential basic training for medical and non-medical endoscopists and intensive training to allow full accreditation of Scotland's new endoscopists.
• Launch a Scottish Education Programme for Endoscopy Assistant Practitioners, accelerating the development of enhanced practitioners (ADEPt) approach. This programme will enable safe and sustainable expansion of the workforce. It will enhance skill mix and enable compliance with the JAG recommendation for staffing numbers and skill mix within our endoscopy services.
• Develop an Academic Training Programme for Urology Advanced Nurse (non–medical) Practitioners with cystoscopy skills in collaboration with our delivery partners, Scottish Access Collaborative, NHS Education for Scotland, Nursing and Midwifery Allied Health Professional (NMAHP) and clinicians. This Programme will provide an academic framework, underpinned by best clinical practice for registered practitioners, with an interest in Urology.
• We will continue to support the expansion of the existing Endoscopy Academic Training Programme for nurses at pace, thus increasing the number of staff trained to deliver endoscopy services. This will be supported by the JAG Endoscopy Training System (JETS) workforce training programme.

Key Areas – Infrastructure Innovation and Redesign

Optimised Patient Choice – We will evaluate and implement alternatives to optical endoscopy where these are shown to be safe, add clinical value; reduce risk, and where these are acceptable to patients. We will implement Urology Diagnostic Hubs and 'One Stop' Clinics empowering patients, enabling shared decision‑making between the professional and the patient around alternative treatment options.

• Continue the successful roll out of Cytosponge^TM* – Cytosponge^TM is a new procedure that provides a less invasive alternative to upper GI endoscopy for the diagnosis of early oesophageal cancer. Ten health boards in Scotland have successfully implemented Cytosponge^TM and plans are in place to expand this to the remaining health boards.
• Transnasal Endoscopy (TNE) implementation. This is a minimally invasive upper endoscopy procedure that provides an alternative to traditional optical endoscopy. It can be provided in a clinic environment, does not require sedation and improves the patient experience. Where practicable, TNE will be implemented across NHS Scotland.
• Colon Capsule Endoscopy (CCE) implementation. This is a new investigation that provides an alternative to traditional optical colonoscopy. Safety, efficacy and cost effectiveness data collection continues. This data will inform the appropriate application of CCE as a diagnostic test in the investigation of lower GI patients.
• The redesign and implementation of Urology Diagnostic Hubs and 'One Stop' clinics – Urology Diagnostic Hub enables the delivery of clinical review and cystoscopy in an outpatient setting. There are Hubs in five health boards and further hubs will be developed across Scotland. 'One Stop' urology clinics provide the efficient and patient-centred care and management of urology patients, reducing the number of visits a patient is required to attend, provides rapid access to diagnostics.