Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon - Y Bumed Senedd

Health, Social Care and Sport Committee - Fifth Senedd

29/11/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Angela Burns
Dai Lloyd Cadeirydd y Pwyllgor
Committee Chair
Dawn Bowden
Helen Mary Jones
Julie Morgan
Neil Hamilton
Rhianon Passmore

Y rhai eraill a oedd yn bresennol

Others in Attendance

Andy Glyde Ymchwil Canser y DU
Cancer Research UK
Asha Kaur Bowel Cancer UK
Bowel Cancer UK
Dr Andrew Goodall Llywodraeth Cymru
Welsh Government
Dr Chris Jones Llywodraeth Cymru
Welsh Government
Dr John Green Bwrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Cardiff and Vale University Local Health Board
Dr Quentin Sandifer Iechyd Cyhoeddus Cymru
Public Health Wales
Dr Sharon Hillier Iechyd Cyhoeddus Cymru
Public Health Wales
Dr Sunil Dolwani Bwrdd Iechyd Lleol Prifysgol Caerdydd a'r Fro
Cardiff and the Vale University Local Health Board
Dr Tom Crosby Canolfan Ganser Felindre
Velindre Cancer Centre
Hayley Heard Iechyd Cyhoeddus Cymru
Public Health Wales
Jared Torkington Bwrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Cardiff and Vale University Local Health Board
Lowri Griffiths Bowel Cancer UK
Bowel Cancer UK
Phedra Dodds Bwrdd Iechyd Lleol Addysgu Powys
Powys Teaching Local Health Board
Simon Dean Llywodraeth Cymru
Welsh Government

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Claire Morris Clerc
Clerk
Lowri Jones Dirprwy Glerc
Deputy Clerk
Sarah Hatherley Ymchwilydd
Researcher

Cynnwys

Contents

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau 1. Introductions, apologies, substitutions and declarations of interest
2. Gwasanaethau endosgopi yng Nghymru: sesiwn dystiolaeth gyda Bowel Cancer UK a Cancer Research UK 2. Endoscopy services in Wales: evidence session with Bowel Cancer UK and Cancer Research UK
3. Gwasanaethau endosgopi yng Nghymru: sesiwn dystiolaeth gydag Iechyd Cyhoeddus Cymru 3. Endoscopy services in Wales: evidence session with Public Health Wales
4. Gwasanaethau endosgopi yng Nghymru: sesiwn dystiolaeth gyda Rhwydwaith Canser Cymru 4. Endoscopy services in Wales: evidence session with Wales Cancer Network
5. Gwasanaethau endosgopi yng Nghymru: sesiwn dystiolaeth gyda Bwrdd Iechyd Prifysgol Caerdydd a'r Fro a Bwrdd Iechyd Addysgu Powys 5. Endoscopy services in Wales: evidence session with Cardiff and Vale University Health Board and Powys Teaching Health Board
6. Gwasanaethau endosgopi yng Nghymru: sesiwn dystiolaeth gydag Addysg a Gwella Iechyd Cymru 6. Endoscopy services in Wales: evidence session with Health Education and Improvement Wales
7. Gwasanaethau endosgopi yng Nghymru: sesiwn dystiolaeth gyda swyddogion Llywodraeth Cymru 7. Endoscopy services in Wales: evidence session with Welsh Government officials
8. Cynnig o dan Reol Sefydlog 17.42 (vi) i benderfynu gwahardd y cyhoedd o weddill y cyfarfod hwn ac o'r cyfarfod ar 5 Rhagfyr 2018 8. Motion under Standing Order 17.42 (vi) to resolve to exclude the public from the remainder of this meeting and for the meeting on 5 December 2018

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Dechreuodd y cyfarfod am 09:16.

The meeting began at 09:16.

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
1. Introductions, apologies, substitutions and declarations of interest

Bore da i chi i gyd, a chroeso i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. O dan eitem 1, a allaf i estyn croeso i'm cyd-aelodau o'r pwyllgor yma? Rydym ni wedi derbyn ymddiheuriadau oddi wrth Lynne Neagle y bore yma, ac rydym ni ar ddeall y bydd Dawn Bowden yn cyrraedd yn hwyr. A allaf i'n bellach egluro bod y cyfarfod yma'n ddwyieithog? Gellir defnyddio clustffonau i glywed y cyfieithu ar y pryd o'r Gymraeg i'r Saesneg ar sianel 1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar sianel 2. Os bydd yna larwm tân yn canu, dylid dilyn cyfarwyddiadau'r tywyswyr, achos nid ydym yn disgwyl ymarfer y bore yma. 

Good morning to you all, and welcome to the latest meeting of the Health, Social Care and Sport Committee here at the National Assembly for Wales. Under item 1, may I welcome my fellow members of this committee? We have received apologies from Lynne Neagle this morning, and we understand that Dawn Bowden will arrive later. May I further explain that this meeting is bilingual? The headphones can be used for simultaneous translation from Welsh to English on channel 1, or for amplification on channel 2. In the event of a fire alarm, we should follow the directions from the ushers, because we're not expecting a drill this morning.

2. Gwasanaethau endosgopi yng Nghymru: sesiwn dystiolaeth gyda Bowel Cancer UK a Cancer Research UK
2. Endoscopy services in Wales: evidence session with Bowel Cancer UK and Cancer Research UK

Felly, mae hynny'n dod â ni at eitem 2 a'n hymchwiliad ni i wasanaethau endosgopi yma yng Nghymru, sesiwn dystiolaeth gyntaf y dydd—y sesiwn gyntaf o nifer sylweddol y diwrnod hwn—ac yng nghwmni Bowel Cancer UK a Cancer Research UK. Felly, i'r perwyl hwnnw, mae'n bleser croesawu i'r bwrdd Lowri Griffiths, pennaeth Cymru, Bowel Cancer UK; Asha Kaur, pennaeth polisi ac ymgyrchoedd, Bowel Cancer UK; a hefyd Andy Glyde, rheolwr materion cyhoeddus Cymru, Cancer Research UK. Diolch yn fawr iawn i'r tri ohonoch chi am fod yma. Diolch yn fawr iawn hefyd am y doreth o wybodaeth rydych chi wedi'i chyflwyno ymlaen llaw. Ac yn seiliedig ar hynny, rydych chi'n mynd i gael toreth o gwestiynau hefyd rŵan. Bydd nifer ohonyn nhw ac mae amser wastad yn brin, felly bydd y cwestiynau yn gryno, gan obeithio y bydd yr atebion hefyd yn gryno. Helen Mary'n mynd i ddechrau.

So, that takes us to item 2, our inquiry into endoscopy services in Wales. This is the first evidence session of the day—the first of a number on this day—and with Bowel Cancer UK and Cancer Research UK. So, to that end, it's a pleasure to welcome Lowri Griffiths, head of Wales, Bowel Cancer UK; Asha Kaur, head of policy and campaigns, Bowel Cancer UK; and also Andy Glyde, public affairs manager, Wales, Cancer Research UK. Thank you very much to the three of you for attending. Thank you also for the reams of information that you have submitted beforehand. And, on the basis of that, you're going to have a load of questions as well. There will be a number of them and time is always scarce, so the questions will be brief, in the hope that the responses will also be brief. Helen Mary's going to start.

Diolch, Dai. Good morning, everybody. In your written evidence, you identify significant concerns about a lack of capacity in endoscopy services in Wales. Taking those concerns into consideration, how confident are you that NHS Wales will deliver the national roll-out of the new faecal immunochemical test screening test by June 2019?

Do you want me to go? I suppose the reason for the inquiry, really, is actually addressing some of those concerns that perhaps the NHS is not in a position at the moment to deliver on the capacity and demand that is going to be required to deliver on the new FIT test. As it stands, because it's likely to increase uptake just because it's an easier test to use, and if we moved to the new threshold that is being talked about for 2023, and reduce the age, then certainly the NHS, at the moment, is not in a good place to be able to meet those needs. So, our concern, and we've written it in our evidence, is that it will actually crash the system. 

I'd just add to that that the lack of capacity is probably the single biggest barrier to introducing the new faecal immunochemical test into the screening programme in Wales, as well as lowering the screening age to 50 and lowering the sensitivity threshold.

I think the only thing to add to that as well is that that's part of the reason for phasing the roll-out from January onwards, just to check. And I think we just need to keep an eye on how the service is managing, and making sure that we are ready to launch, hopefully, in June in full.

Thank you. You've answered this in part, but I'll ask in case there's something that you need to add. We understand that Bowel Screening Wales will screen from the age of 50, every two years, at a more sensitive threshold by April 2023, as you've just mentioned. To what extent has this target, do you think, been determined by the current endoscopy capacity? Is the capacity leading the target, rather than the other way around?

09:20

I think, probably, in terms of the timing of the target, it is to give, in theory, time for the endoscopy services to increase their capacity. I think the important thing to note there is, if we get to that point by 2023, that's where Scotland is today. So there's a question of ambition there as well: whether or not, actually, we should be going a bit further, thinking that probably Scotland's not going to stand still over the next four years on this and we're still going to be behind the curve, even if we do meet that target. 

Thank you. In that regard, is Scotland meeting its target, because obviously the lower that threshold, the safer it is for the citizens of Wales? So, in that regard, is it highly ambitious and likely for Scotland, in your view?

Sorry, I didn't understand the question. 

So, in terms of that 80 μg FIT threshold that they have in Scotland, is that, in your view, hittable for them and are they managing it? So, in terms of our capacity and in terms of what we then need to do to roll out our systems in terms of capacity.

It's quite a complex thing for Scotland in terms of—. At the moment, obviously, the demand is increased. I think, anecdotally, we're hearing that there has been an increase in demand for endoscopy services. I think it's fair to say, as to our system here in Wales, the quality agenda is really, really high, so the quality of our colonoscopies are really, really sound in terms of being accredited. They have a different system of accreditation in Scotland. So maybe they're able to get more people through the system. So whilst they're able to meet some of the demand that has been created by the introduction of FIT from 80 μg in Scotland, they're able to get through more numbers, whereas we are probably—. There's a crisis in what we currently have available in terms of capacity, but also then I think we need to congratulate ourselves, actually, on the quality of the service we're providing when we do have it, but we just need more of it. 

Okay; thank you. I think I can follow what you're saying. 

Just about. [Laughter.]

Yes. [Laughter.]

So, in that regard—. I have a question around this. In that regard, we're talking about capacity; what does that look like in terms of what we have to have in place in order to be able to increase the supply of diagnostics and also lower that threshold so that it's at a better level in Wales?

Well, one of the things we need is more NHS staff to be carrying out endoscopy tests. So, when someone takes a FIT test and it detects hidden blood in the poo samples, they'll be referred for a colonoscopy to either diagnose bowel cancer or rule it out. Because FIT is a more accurate and more sensitive test, and because it can increase uptake, more people will be referred on for a colonoscopy and, at the moment, there just simply aren't enough NHS staff to carry out the number of diagnostic tests required. 

On top of that, we also need to use current capacity more productively and more efficiently, and we also need to manage the demand going into the system. So, initiatives like using the FIT test in primary care potentially could help to manage that demand going through to colonoscopy services. 

Okay, thank you. So, in your view, it's quite clear from what you've already stated that an increase in the usage of this test will increase demand. So in that chicken-and-egg situation, as has been referenced, could you extrapolate a little bit more for me, in terms of training of staff, what other things need to be in place so that we're ready for the FIT test?

Cancer Research UK has been looking at this quite a lot around the diagnostic workforce as a whole—not just endoscopy, but with a particular focus on endoscopy. I think there are a few different things that probably need to happen at the moment, where we need to look at the long term: how do we meet demand, how do we make sure that we've got the right workforce in place, and the new Health Education and Improvement Wales, I think, has got a really important role to play there. I think—

Well it was only just set up, in October, so I think it's still trying to find its feet. 

It may only just have been set up, but this could be one of its—

We would really like to see Health Education and Improvement Wales prioritising diagnostics. We've been told that, actually, they need to spend a little bit of time setting out their strategic direction, which again creates a delay in then prioritising what their work programme is going to be. So, is that going to be 12 months before they even start looking at—?

Absolutely.

So, we'd love to see HIW prioritising diagnostics for—. Well, it's not just cancer that, obviously, you'd find as a result of those diagnostics tests—there are other diseases as well, such as Crohn's and colitis, which are equally debilitating for people. Obviously, we're here talking about cancer, but others would—. 

09:25

And linked to that as well, we don't really have a huge amount of data in terms of what the gaps actually are. We know that there are gaps. We don't know exactly how many endoscopists we're lacking and how many we need. And so, almost—.

Well, we can guess that we are. So, in terms of how we then propagate that, what steps would—

So, we would like to see an audit take place of the whole diagnostic workforce to be able to identify those gaps, to be able to then feed into HEIW's work. But then, as Asha mentioned just now, it's about that skills mix and how we make use of other staff, so nurse endoscopists [Correction: 'non-medical endoscopists], to be able to free up capacity elsewhere as well. So, there are a few things that can be done.

We know that, right now, health boards are doing a lot of insourcing and outsourcing, which is helping in the very short term but isn't sustainable and is very expensive. So, I think we need to get to a point where health boards can move away from that, to that kind of more long-term solution, really. 

Okay. Moving on, Neil, on the same sort of subject area, really. 

Yes, it's about diagnostic service capacity and waiting times. Diagnostic endoscopy services have seen the largest decrease in median waiting times in 2017-18—indeed, a sharp decline in the first couple of months of this year. Those are the latest figures that we've got. But it's still clear that demand for diagnostic tests is outstripping capacity, and despite the task and finish group's recommendations and the extra funding that was provided as a result of that to improve waiting times, significant challenges clearly remain. Some witnesses have suggested that this demonstrates that a radical redesign of the current system is needed. Do you agree with that? 

Totally. Absolutely totally agree with that. Yes, you'll probably find if you look at the waiting times that, actually, things have improved. But as Andy's pointed out, that is as a result of investment from Welsh Government, absolutely, which is very, very welcome, but that money's been directed to waiting time initiatives to get the waiting times under control. And what you then find is that the time and the money that need to be spent on redesigning the system and finding those long-term, sustainable solutions, we're not seeing that.

And to be fair to Welsh Government and the NHS, they are looking to set up a programme of activity around endoscopy, but we would argue that we had a task and finish group looking at this very issue back in 2013-14 and, actually, a lot of the recommendations from that task and finish group have not been delivered. So, what we'd like to see, obviously, is actually a revisiting of those, perhaps. We don't need to talk about what the problems are; we know what the problems are, but we just need that action now. You know, let's take this out of the committee rooms of these corridors and Cathays Park, and actually get some delivery on the ground, which is actually where the difference is going to happen, because at the moment we're not seeing that. We're seeing a lot of talk, a lot of rhetoric, a lot of nodding of heads to say, 'Yes, there's a problem', but we haven't seen any definitive action.

We're hopeful that the programme that's been put forward by Welsh Government and senior colleagues in the NHS will deliver, but we haven't seen any pace behind that. We're still 18 months down the line from when we both started in our posts to actually seeing any definitive action. So, we really need to gather some pace on this, because FIT is coming in in January, and by 2023 we want to be screening from 80 μg and from 50 years of age and, actually, we want to take it even lower than that in terms of the thresholds. So, the lower the number, the higher the sensitivity. There's a lot to do.

So, the diagnosis is clear and it's already there; you don't need to do any more work to identify problems—it's simply a case of implementing what's already been suggested. 

I think there's some work to be done in terms of identifying the capacity gaps, and then getting senior clinical buy-in at health board level, which doesn't seem to exist at the moment, getting the finance people in the same room as the planning people, and getting that strategic buy-in. And, hopefully, from Welsh Government, that direction will come to actually make this happen, which we haven't seen.  

Very briefly, in that regard, you've mentioned the endoscopy programme, and I know we'll probably refer to that later on. So, in terms of the timeline around that, because obviously that's going to be a critical lever in this in terms of moving that forward, et cetera, and the pace, what's the expectation around that? 

'We don't know', is the answer. I don't think we've been given a time frame, and I think that's something that we do need quite desperately as soon as possible. 

09:30

Yes, on this point—following on from that, really. So, to what extent do you think that the new national endoscopy programme addresses the concerns that you've raised about a clear lack of leadership from Welsh Government, the NHS Executive and health boards in addressing these capacity issues?

It's really difficult to say definitively, because we haven't really seen anything come out of that programme yet. Again, it's relatively new. It's sort of been moved into the NHS collaborative from Welsh Government's previous endoscopy implementation group. But, I think, again, it's that pace of change. We do need to see some plans fairly soon. 

And there's a slight difference in approach between Bowel Cancer UK and Cancer Research UK. 

From the written evidence, because Bowel Cancer UK says that the problems are

'due to a lack of clear leadership within NHS structures to make Wales wide strategic decisions
on the best way to approach introducing the FIT test for use with symptomatic patients, it is
yet to be introduced.'

And Cancer Research UK seem a bit more cautious, saying

'there are still unanswered questions of how the implementation of FIT in symptomatic patients will work in primary care.'

I would go on record here saying that we do feel that there is a lack of strategic direction, or there has been up to this point. I think now—. And you're going to have a lot of very important people in this room later on today, who will tell you—

We've got very important people in this room now. [Laughter.]

Thank you. [Laughter.] No, so, you know, very important people within the NHS who are going to sit here today and tell you that everything is in hand. And I suppose that's our concern. And when we approached the committee to potentially carry out this inquiry, it's about, 'Actually, how do we get this on public record now? We've gone through this in 2013-14.' These recommendations have been made already that something needs to happen. And, in the meantime, FIT has been coming down that track like a train loaded, and we have not moved forward, in our view, very far at all. And there's a lot of frustration in the clinical community, and I think, actually, they're just like, 'Bring it on. Bring it on. Let's actually—.' We need the pressure to actually make the changes actually happen. Unfortunately, what that means for patients is that they're going to be waiting longer, and actually, you're going to have people having a positive FIT result who are not able to actually access that diagnostic in a timely manner.

And that is why we are quite outspoken about that we need that strategic leadership, but it's quite subtle within the health boards about how that's organised. And I'm not clever enough to understand how that is. Somebody somewhere needs to have an understanding of how the planning, the finances, the clinical community, and executive strategic leadership come together to make this happen, because otherwise it's going to be a disaster.

Okay. Thank you, Neil. Angela, the floor is yours. 

Thank you. I think some of the questions I wanted to ask have already been answered. But do you know which health boards are outsourcing, or insourcing? 

We know the ones that have submitted evidence. We've seen that in those. I think the issue is that there is that, as Lowri was saying, kind of lack of a national approach, which means that health boards are kind of on their own. They're under pressure to meet waiting time targets for both endoscopy waiting times and cancer waiting times, and they're not given that space to be able to really think long term and find those more sustainable solutions, and so just throwing money at outsourcing and insourcing— 

We talk a lot, though, about national approaches on so many things here, and sometimes it's just—the real situation is that it ain't going to happen. So, I'm quite interested to understand, on a health board by health board basis, which ones are the ones who really aren't getting to grips with this, because if we can't tackle a national set of objectives, maybe we can tackle it a different way, because there are lots of different ways of trying to resolve this. Because, ultimately, however we do it, we just want it resolved. So, it would be really useful to have a very clear understanding of what your perception is of what the health boards have said in their evidence, because there's always going to be a difference of opinion. 

I don't want to sit here and name health boards who are—

No, but that's the problem, you see, people never do, and then—but you ask us to solve a problem. 

Yes. Well, absolutely. We can—. I can get you that evidence. I haven't read the 145 page documents, and I think only three health boards—Powys, Cardiff and Vale, and Cwm Taf, is it, have responded. So, you know—. And Cardiff and Vale, in their evidence, have been very open about their what they call insourcing. So, they're getting people from outside to come in and use their facilities, as opposed to outsourcing, which is sending people to private facilities. So, they've been very open about that. It's something you can go away and identify.

09:35

Sorry. The joint advisory group for gastrointestinal endoscopy carried out a national endoscopy audit in 2017, and some of the questions they asked were about outsourcing and insourcing. So, there might be some evidence and data there to look at, to see which health boards—

I'd be interested in that. And, in fact, Asha, that brings me on to the other question that I wanted to ask, which was about—because I saw that there was the 2017 audit. Did it break it down, though, into where the waits are? So, are the waits universal, are the waits for diagnostic, what are the waits for surveillance, what are the waits for actual treatment because they found something untoward? Because I think that would also be quite an interesting journey to try and plot. And I wondered if you had that kind of information.

I'm not sure if the audit broke it down by referral route, but I think what we do know is that there are breaches across probably all referral pathways in, because the endoscopy capacity is constrained. And, obviously, no matter which referral route people are being referred from—whether that's through the GP, screening or surveillance—they're still being referred into the same diagnostic service, and the diagnostic service is overstretched and doesn't have enough staff to actually deal with all the sources of demand that are coming into the system.

So, are you saying there's a gap, then, between the diagnostic service and the surveillance? Because my understanding was that surveillance fed straight in, so it was an auto-recall that was just slotted in to the diagnostic, or into the endoscopy, service.

I think what you find, and, again, I think reading some of the evidence that's been provided by health boards, actually, the surveillance, which is patients who are at a high risk—so people who may have colitis, Crohn's, that kind of thing, who should be having routine endoscopies to actually keep an eye on them so that if they do get cancer they'll catch it nice and early—. I think that what you're finding is that to prioritise the waiting time requirements, in terms of performance measures that they have to report on, they might sacrifice those surveillance lists, because there's no reporting to Government or the wider NHS on those particular surveillance cases. So, what you've got, which is crazy, is high-risk patients who are being—. My husband is one of them, for example. He has colitis, and he's never had a recall for a colonoscopy, even though he was diagnosed with colitis going back over 10 years ago. So, he's never had a recall, even though he, because of his condition, is at high risk of bowel cancer. So, you have things like that happening within the system, because of the way the system is organised. And I think, with all the best will in the world, you've got clinicians, managers, finance directors, chief executives, under huge pressure out there, but what we say with bowel cancer—this disease is preventable. So, if you get the screening right, you can actually prevent the cancer—you remove the polyps, which the screening identifies, and actually you will prevent the cancer in the first place. It's low-hanging fruit, in the words of a clinician who you'll speak to later, Jared. So, if we get bowel cancer nailed, it can go from being the second-biggest cancer killer, to—actually, we believe that nobody should be dying from bowel cancer. And the key to that is endoscopy.

No, I totally get that. So, just so that we completely understand the surveillance process: so what we ultimately want then is a system that calls someone forward—I don't know, because of age, or because they have colitis or risk or whatever it is—they're called forward, they're checked out. It's either, 'You're fine, go away, see you in X years' time', or, 'You're at risk, we want to see you in six months, or one year.' And so we want a system that programmes those recalls in automatically, so that, whatever happens—on November the whatever we are—that person is popped up on that date, no matter what else is around it. So, really we're looking for—. So, there's the pressure that's letting us down, there's perhaps people not programming it in, because are people going back to paper-based notes? Is it automatically being—? Is there a system? Is there like an endoscopy recall system that takes, you know, 'Lowri Griffiths', pops her in there, and then says, 'Right, back in five years, back in two years, back in six months', and you pop up on that due date, in those particular times? So, is it the technology as well that we need to surveil this, as well as then having—? Because we're looking at another inquiry at the moment, where it's about driving change—and I absolutely get your argument about let's create the need and that will help to drive the change. So, yes, bring it down to 50, yes, put in FIT, et cetera. But I want to make sure that we have the systems in place that would deal with it, to surveil it. 

Absolutely. I think it's all—. I think health boards have got different systems to address their different pathways. So, you've got surveillance pathways—you talk about those people at high risk; you've got people coming in on the symptomatic, and you've got the screening. So, they're dealing with all sorts of different things and I think the challenge with endoscopy doesn't quite sit within any directorate. We've heard that as well before, haven't we? So, it's kind of like a bit of a floating—. Because it services so many different kinds of areas and disease groups. So, there are challenges. So, I think the answer to that is that there is no national system.

09:40

Okay, so a quick answer then, again, to go back to surveillance: should we then say that every single person who is at risk should automatically be put onto the Bowel Screening Wales system, and they take it forward and they act as the umbrella?

Absolutely, and that's something that Bowel Cancer UK have been calling for for quite some time, a national approach to dealing with these high-risk patients who need to be seen yearly, two yearly, because they're at high risk of bowel cancer, and a national approach would be favourable because it would mean that these people, who we know have a high chance of getting bowel cancer, are seen on time and regularly and are being provided with high-quality services.

Just to make sure I understand: Bowel Screening Wales doesn't deal with anybody younger or with other conditions.

It was going back, actually, to the outsourcing and the insourcing that Angela was asking about: if health boards are using that, because they've got such a huge number of people to deal with, in itself, as a short-term solution, as long as there's long-term planning going on as well, surely that is not something that we should decry.

No. No, absolutely—as long as they're both going hand in hand. And, in our recommendations, we say we want to plan to see the decrease in outsourcing—the redesign, the capacity redesign and that remodelling of services. And obviously, then, when you get that, you're going to increase the capacity and then obviously then you're going to have the outsourcing. It's just going to carry on and they all do it, and absolutely—

It would be better if they didn't, but I think, you know, in the circumstances—

And then you're going to get a balance then, aren't you? So, yes, it's not a case of, 'Let's just stop outsourcing', because obviously then you're going to have patients waiting even longer and it is okay to have patients go in on a Saturday or in the evenings or something like that, if they're getting their endoscopy, but it's very expensive.

And it's just not sustainable.

Yes, which is what we're lacking.

Just taking this back to the surveillance issue, you said you think we need a national approach. Do we need targets? Does the service need to have targets set around surveillance?

I think that could be potentially helpful in making sure these high-risk patients are seen on time, certainly with people who are referred urgently for the system. The waiting time targets have helped to an extent to make sure that patients are seen on time and it could help here too.

Okay. Happy? Okay, Julie, the last couple of questions are with you. Some of them have partly been answered already, but feel free—

Yes, I was just going to ask about workforce planning and the poor data, which I think you've already referred to. Basically, health boards are doing what they can afford rather than doing what's the best thing. What suggestions have you got about health boards overcoming their current and future diagnostic workforce challenges?

For Cancer Research UK, it is all about, you know, we've got this brand new body, Health Education and Improvement Wales that is supposed to be coming in and providing a new, nationally driven, strategic look at workforce planning for the whole health service. We would like them to take a really clear focus on diagnostics, because I think that's where we know there are gaps at the moment, and to support health boards in things like capacity and demand modelling and then looking ahead to how many training places we need, making sure they're happening and looking at different ways we can use skills mixes and things like that. So, I think we're expecting a workforce strategy to come out of HIW at some point, once they've really got going, and I think we would be really keen to see diagnostics be a real priority in that strategy.

Right, thank you. And then what is your position on delivering a FIT test at a very sensitive level—i.e. 10—in the primary care setting, looking at people with vague symptoms of bowel cancer, who wouldn't be put on the urgent list?

I think—we know there's evidence that this can make a really big difference. I think we need probably more in terms of—you know, there is a difference between using this with low-risk and high-risk patients, so what's the best way to approach it? We know that some health boards are ploughing ahead, because they know that this will make a difference to them, but, again, it's whether an all-Wales approach would be better, to make sure that the equipment that we need to do those tests and to make sure that we have equity and parity across Wales in terms of the way that we're doing that is in place, really.

09:45

I think there are still a lot of unanswered questions around FIT in the symptomatic population, mainly what to do with patients who have a negative FIT. You know, what strategy do we take with those patients? So, I think that, whilst there is potential for FIT to help decrease demand on diagnostic services, we just need to make sure that it is used safely and effectively.

And then, also, linked to that as well, we know there's a little bit of evidence to suggest that some patients might still be missed through that. And so, it's making sure that there is proper safety netting in place so that, if people go through the FIT and have a negative result, then they're still being followed up and checked if they're experiencing symptoms.

Thank you. And the last question—this is to Andy, actually: you're calling to increase the uptake target for bowel cancer screening in Wales from 60 per cent to 75 per cent. What sort of time frame would you set for that, and is this realistic, do you think?

Yes, I think it's very much a long-term thing. We've not hit the 60 per cent target since the programme was established. It's something that we've been supporting with Bowel Screening Wales. So, earlier this year, we did an uptake campaign with them, the 'Be Clear on Cancer' campaign, and the early results are showing that that did have an impact on uptake. I suppose that, if we're going to reach that target, then, again, what are the long-term plans to make sure that we do that? Running a tv-led advertising campaign, as we did for 'Be Clear on Cancer' in February and March this year, is quite expensive—are there the resources available to Bowel Screening Wales to look at that? Other interventions—you know, there are other ways to increase uptake that have got a lot of evidence behind them. But we know that we do need at the very least to reach that 60 per cent target sooner rather than later so that we're saving more lives.

I would just add to that that if we do want to increase the uptake of screening, FIT is the best way to do that. Research on the pilots has shown that FIT can increase uptake by around 10 per cent, particularly in previous non-responders and first-timers. So, if we do want to get to that 75 per cent target, then we need to introduce FIT as soon as possible.

Very briefly. In terms of the negative FIT test that you talked about and the concern around that in terms of future diagnosis, is that purely dependent, then, on the threshold that it's set at? Because, obviously, it's very variable now across the UK, and you've already mentioned that some health boards may be having, perhaps, best practice in a lower threshold anyway. So, is there a concern around that?

I think it's important to separate the two things out. So, you've got the screening threshold, which has been set for Wales at 150, coming in next year, then you've got this kind of movement towards setting the threshold within primary care for those who present with symptoms at 10, and there's some argument that it should be around seven, because what they say is that, at around about 10, you're going to—

[Inaudible.]—couple of cancers.

A couple of cancers, yes. So, even though it's really, really sensitive, some say it should be around seven, because it detects that tiny microscopic level. So, I think it's important to distinguish between the two levels, and we want to get the population-level screening level right down to 80 first, and then beyond that as well. Hayley, who will probably speak later, always talks about actually getting it as optimal as possible. So, there are two distinct things there. But the issue that you've got with bringing it down to 10 in primary care is: can you guarantee that every cancer bleeds? And I think that that's the issue. I don't know if you can. Dai, you're a GP; would you be confident with your negative 10 FIT result?

Yes. So, it's really complex, and I think there's a lot more work that needs to be done to do that research, to actually give it that evidence base, before it's actually rolled out across primary care or, as some people say, within secondary care as a stratification tool.

I know we're running out of time, but in terms of the mention earlier on of a more national approach around this on many levels and the radical redesign that you've spoken of, have there been any costings attached to this? Because we're talking about things in isolation in terms of Health Improvement Education Wales et cetera. Have you, as organisations in the third sector, had any scope to look at what this radical redesign is?

In terms of costings, it's really difficult for us to say for certain.

Because, obviously, the NHS is under huge pressure from all cancers, from all conditions.

09:50

I think what we do know is that if we're going to hit that 2023 target—just talking about FIT screening for a second—we're going to need an additional 15,000 colonoscopies every year. So, it's significant. I think that's where having that kind of national leadership is really important to be able to identify exactly what that cost will be. I think it's really important to note that doing nothing is not cost free either, as we've seen. It will become more expensive to try and do the short-term initiatives to manage this and get patients through in endoscopy than having that longer term, strategic focus.

I think the Wales cancer network have actually done some costings in terms of an overall figure that may be required to meet some of that demand in future years. But, again, we don't have the detail or the insight of that, but they are on it. 

I think I'd also say that whilst there might be upfront investment in terms of redesigning the service, there are also those long-term gains to be made. Because the earlier you diagnose bowel cancer, not only is it more treatable and curable, but it's also cheaper to treat at stage 1 than it is at stage 4.

Grêt, diolch yn fawr. Dyna ddiwedd y cwestiynau a dyna ddiwedd y sesiwn. Diolch yn fawr iawn i chi am ateb y cwestiynau mewn ffordd mor aeddfed a graenus jest rŵan, a hefyd am gyflwyno'r holl dystiolaeth ysgrifenedig ymlaen llaw. Mae wedi gosod llwyfan haeddiannol gogyfer gweddill y diwrnod. Fe gawn ni weld sut yr aiff hi. Diolch yn fawr iawn. Fe fyddwch chi yn derbyn trawsgrifiad o'r trafodaethau yma er mwyn i chi allu gwirio eu bod nhw'n ffeithiol gywir. Diolch yn fawr iawn.

I fy nghyd-Aelodau, fe wnawn ni dorri rŵan am ryw ddwy funud er mwyn cael y tystion nesaf i mewn. Diolch yn fawr. 

Great, thank you very much. That is the end of the questions and the session. Thank you very much for answering the questions in such a thorough way, and also for submitting all your written evidence in advance. It's set the platform very well for the rest of the day. So, we'll see how it goes. Thank you very much. You will receive a transcript of these proceedings so that you can check for factual accuracy. Thank you very much.

To my fellow Members, we will break for two minutes before the next session. Thank you very much. 

Gohiriwyd y cyfarfod rhwng 09:51 a 09:55.

The meeting adjourned between 09:51 and 09:55.

09:55
3. Gwasanaethau endosgopi yng Nghymru: sesiwn dystiolaeth gydag Iechyd Cyhoeddus Cymru
3. Endoscopy services in Wales: evidence session with Public Health Wales

Croeso nôl i bawb i'r adran ddiweddaraf o'r Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. Rydym ni wedi cyrraedd eitem 3 rŵan, a pharhad efo'n hymchwiliad i wasanaethau endosgopi yma yng Nghymru. Dyma'r sesiwn dystiolaeth ddiweddaraf, gydag Iechyd Cyhoeddus Cymru. Felly, i'r perwyl yna, mae'n hyfrydwch i groesawu Hayley Heard, pennaeth Sgrinio Coluddion Cymru, Iechyd Cyhoeddus Cymru; a hefyd Dr Quentin Sandifer, cyfarwyddwr gweithredol gwasanaethau iechyd y cyhoedd a chyfarwyddwr meddygol, Iechyd Cyhoeddus Cymru—un o deitlau hiraf y dydd, rwy'n credu, Quentin, felly da iawn; a Sharon Hillier hefyd, cyfarwyddwr yr adran sgrinio, Iechyd Cyhoeddus Cymru. Croeso i chi'ch tri. Rydym ni'n ddyledus i chi am gyflwyno toreth o dystiolaeth ysgrifenedig ymlaen llaw. Diolch yn fawr iawn i chi am hynny. Fel sy'n draddodiadol, awn yn syth i mewn i gwestiynau, ac mae Rhianon Passmore yn mynd i ddechrau. 

Welcome back, everyone, to the latest section of the Health, Social Care and Sport Committee here in the National Assembly for Wales. We have reached item 3 now, and we continue with the inquiry into endoscopy services in Wales. This is the latest evidence session, with Public Health Wales. So, to that extent, it's a pleasure to welcome Hayley Heard, head of Bowel Screening Wales, Public Health Wales; and also Dr Quentin Sandifer, executive director of public health services and medical director of Public Health Wales—one of the longest titles of the day, Quentin, so very good; and Sharon Hillier also, director of screening, Public Health Wales. Welcome to the three of you. We are grateful to you for presenting an abundance of written evidence beforehand. Thank you very much for that. As is traditional and usual, we will go straight into questions, and Rhianon Passmore is going to start.

Diolch, Chair. Welcome. How confident do you feel that the faecal immunochemical test—FIT—will be rolled out across Wales by June 2019?

Very confident, actually. The plans are progressing really well. The project's on target to implement a phased implementation at the end of January, and we fully expect to roll out nationally in June.

Okay, thank you. In terms of comments that we've had previously, there seems to be concern around the diagnostic capacity to be able to keep up with this roll-out on the date that we've discussed across Wales. So, what is your comment around that?

So, we're planning to introduce FIT as a phased implementation. In terms of that process and the FIT, I think that there will be capacity in terms of that process going forward. With the FIT implementation, I think it's just important to explain why it's a phased implementation as well. So, this is going forward on work that we've done in terms of implementing human papillomavirus and cervical screening, where we're doing a phased implementation to see how the programme copes and performs in that way as well, so we can learn around that process, so that when we implement in June, that implementation will go really well.  

Okay. Angela's got a supplementary on this point.

Just on this one point: when you're looking at your phased implementation, how are you choosing the health board areas that you're implementing into?

We're not, actually. We're going to send a FIT kit to one in 28 people. So, we invite by date of birth rather than by geographical area, so it will be spread across Wales.

We felt that that was the only fair way of distributing the invitations, so it will be a random one in 28 people who receive a FIT kit. 

Okay. I just wondered if it might be the areas where the endoscopy services were better.

No, it isn't.

So, to clarify further—that's very interesting, actually—when will it be 28 out of 28? When will it be full roll-out? I know you said 2019, but is that—?

Yes. One in 28 from the end of January; everybody receiving a FIT kit from the beginning of June. Then, we've developed an optimisation plan that we submitted to the Wales screening committee, which hasn't yet been formally approved. Our plan would be to optimise age expansion because we think that would be where the public health benefit would be greatest. So, we would sustain the FIT at 150 probably until April the following year and then expand the age range.  

Okay. And with regard to the one out of 28—because this is ambitious—by June 2019, how have you based your assumptions, as the expert body, that we have the capacity to actually be able to cope with the demand by 2019?

If I could come in here, we have been aware of the requirement to introduce FIT for about three years. We have spent that time very carefully working with all the health boards to plan for this. So, we are preparing for the end of January on the basis of at least two years of planning, talking to the health boards, acknowledging the challenges within the health boards, and it is an agreed, pragmatic position that we can start with the one in 28 basis. Of course, that will then accelerate within a matter of three or four months to a full coverage, with the opportunity to learn as we go along. And that, as my colleague Sharon indicated, is from our previous learned experience with the introduction of other programmes. So, we don't intend to start with not being able to do what we say we're going to do, but we're also realistic, as we've learned with HPV, for example, where, I have to say, we are ahead of other parts of the UK in this, where we implement in a way that we can manage the process through to the objective that we're seeking to at the earliest possible date, which, in our case for bowel, we are saying is June next year.

10:00

Okay, thank you. With regard to the differences in the sensitivity test—for instance, Scotland's at 80 and we are thinking on a different level of 150—what is your view in terms of that being the threshold in Wales?

We are taking a pragmatic view about this. We want to get the FIT threshold down, over time, at the earliest opportunity. We note the Cabinet Secretary's requirement for us to achieve optimisation, both of the FIT threshold and the age extension down to age 50, by April 2023. We're modelling that at the moment, as my colleague has just said, and we await the outcome of the deliberations of the Wales screening committee in response to our advice.

Just briefly, in terms of that outcome, when are you expecting to hear from the Wales screening committee?

The Wales screening committee will decide when it wishes to tell us all, but I guess that'll be very soon.

We have presented, but, again, it has to go through due process of—

And just before I finish my questions, in terms of comments we've received, do you think the whole of the endoscopy sector, and bowel screening in particular—is there a need for a radical redesign of the system?

I think it's incredibly challenging for health boards at the moment. They are making some improvements with waiting times, but that, by and large, is by using short-term waiting list initiatives that don't appear to be sustainable. So, I think—

So, how can you then feel confident that, with even more demand on the system, it's going to be—?

I think because, as Quentin says, we have worked so closely with them over the last two years, they have got plans—they have short and medium-term plans—that I believe are going to enable them to implement FIT. And then we need to be working with them as a national programme, really, to make significant improvements for sustainable capacity going forward.

And I think the point about the 150 cut-off, whilst it's not where we'd like it to be, it's absolutely pragmatic. It is going to deliver improvement on our current test. It will detect more cancers and more adenomas. It'll only increase demand by about 300 procedures a year across Wales. So, it shouldn't significantly challenge them immediately, but it is really important that we work very closely with the health boards to develop that longer term increased, sustainable capacity.

And if I could just add, just for the committee's benefit—and it may well be aware of this, so apologies if you do know this—in terms of the overall endoscopy activity, the screening contribution to that is less than 10 per cent of that whole activity. So, we are very realistic in our estimations of the impact on the totality of endoscopy services.

It's a supplementary to this, really. I always get worried when I hear the word 'pragmatic', although it is sensible, I know. Just for clarity, are you telling us that the fact that we're setting a threshold that is quite a lot higher than the one that's used in Scotland, and higher than the one that's going to be used in England—is that determined, effectively, by the endoscopy capacity? I think that the number of procedures—300 doesn't sound like a lot to me—sounds like an awful lot of effort, and how much benefit—? I'm not a clinician, but I'm left with the question about how many cancers are we going to miss by setting the threshold at this level? Isn't there a case for being a bit more ambitious and saying—well, for us to be saying to Welsh Government, 'You need to be investing', so that we're not setting a threshold that means that people with cancers will not be picked up, or will be picked up later. 

10:05

I think that's a really good point. In an ideal world, we would much prefer to be implementing with a lower threshold, but we've got to look at the bigger picture. It is an improvement on our current activity; we will be picking up more cancers and more polyps without stretching the service to collapse, at the initial implementation. The advice that we've been given from everywhere around the UK, including Scotland, is that this is a very sensible approach—to get it in and then improve as quickly as possible afterwards.

But it's a sensible approach that will mean that some people will get ill who wouldn't otherwise get ill.

But we have to, with all due respect, acknowledge that there are people at the moment who we would be identifying cancers in if we had testing or age extension. So, we accept the challenge, and it is our intention to see this optimised as soon as we can, but we have to work within the realities of the challenges within the service at the moment.

Can I add—? There's a lot of evidence in terms of modelling and public health benefits: the UK National Screening Committee and the School of Health and Related Research have produced extensive models in terms of, if you had the FIT test, how would you implement it to get the best benefit? And it's quite clear from that data that, actually, it's in age extension where you'd gain your public health benefit. The FIT level is really important, but if you think about our population now, which is 60 to 74, they've been invited for some time, so they've had several invitations—some of those—as well. To actually reduce the level in that population, to get the best benefit, you're better off extending the age range, because that's when your quality-adjusted benefits come out, because you're doing this in younger people in terms of going forward. So, I think there's a real concentration on the FIT levels, but, actually, we shouldn't forget about actually who the eligible population are in Wales.

Okay. Are your own questions covered as well, Helen?

To a certain extent. I just want to unpick a little bit about—. In your paper, you said that all the health boards are currently funded for more screening activity than they're doing, and yet they struggle to deliver that target. Could you just expand on that a little bit and tell us a bit more about what the issues are there? Because if they're being funded to do the work and they're not doing it, then the issue is obviously not money, or not money alone. So, can you unpick that a little bit for us, please?

Yes. The issue isn't money. They have, for some time now, been funded for more activity than they've actually been able to deliver. The main problem, and there are slightly different issues in different health boards, but the main issue is the pressure on the symptomatic service. So, if we lose a screening list for whatever reason, the backfill of that list is nearly always with symptomatic patients. So, we're losing activity and there isn't capacity within the system to put on additional screening lists.

Sorry, Chair, can you just clarify what you mean by 'symptomatic list', because you've lost me?

I'm sorry. The symptomatic service would be the population that develop symptoms and go to their GP and get referred into the endoscopy system—

If we were to lose—. So, the screening lists are set up as dedicated screening lists in each of the local assessment centres, but they sit within the wider endoscopy service, where symptomatic lists are run at the same time—

And if, then, a health board has a run of patients—very crudely—who have symptoms that require investigation, then the health boards sometimes will prioritise that requirement on pre-booked, scheduled screening lists.

The symptomatic service waiting lists tend to be longer than screening, so the management team within local assessment centres often prioritise symptomatic patients over screening for backfilling of lists. So, we tend to lose lists and then are not able to have them replaced by that health board.

That, actually, Chair, was the question I was asking previous witnesses, because where the wait is—. So, what you've just said makes absolute sense, and that, I assume, is why people who are on a surveillance programme get dropped, because the trauma cases, the symptom cases and the more urgent cases—

The more urgent, symptomatic patients, yes.

Yes, it's the accident and emergency department versus elective, in a way.

In a crude sense. I really wouldn't like to be drawn into talking about A&E and unscheduled care, if you don't mind.

10:10

But that's the key thing for us to understand: where those waiting problems sit. So, we almost need a divorce between the, 'Oh my god, I've got something wrong with me now', and the GP saying, 'Go in', and the people who are on that programme of follow-up. Because the previous witnesses were talking about people with things like colitis and Crohn's, who are at risk, just falling through that gap, and I assume that's why. 

'Hot and cold' is probably a better way of describing it. 

Yes. Thank you, Dai, that's it exactly. [Laughter.]

I understand a bit more clearly that there is a problem, but I still can't quite understand what the problem is for the health boards. So, they're being given money and then there is this obvious issue that if you've got a patient presenting with symptoms, I think we'd probably expect them to be dealt with before people who are not yet ill or we don't know they're ill. But if they're being given the resource, why can't they do it? Is it bits of kit, is it not the right people or is it the right people in the wrong place? You have to bear with us: we're not clinicians, but—. 

I think these are questions you may well wish to put to people coming to subsequent sessions. 

Absolutely.

We undoubtedly will, but you've just told us that you've been working with the health boards for three years to prepare for this—

—so you must know the answer to this question. Now, if you want to sit here and tell me that you're not prepared to give me the answer to the question, I'm happy to have that on record, but you can't, on the one hand, tell us that you know that this can be done—ambitious, but you're confident it can be done—and that you've been working with the health boards for three years to get ready to do it, and then not tell us why they're not doing it now, because if you don't understand why they're not doing it now, you can't possibly be confident that they're going to do it in three months' time. 

We do understand, and there are different reasons in every health board, which, I think, just reinforces the need for a nationally directed programme to address these issues. They are multifactorial. They do relate, often, to staffing: that we only have 18 screening colonoscopists in Wales, who are accredited to do screening.

This is the sort of thing that I was hoping you'd be able to tell us. 

We could give you chapter and verse. It's probably best that you get that from the health boards, but, I think, the overall message, really, is that it's really important that there is a nationally directed approach to sorting these problems out. There needs to be a training programme and there need to be workforce initiatives that are ongoing. There are some issues with the environment: some health boards don't have enough endoscopy rooms to manage the demand that they get through. Many have difficulties with nurses: the training of nurses and the recruitment and retention of nurses, equally nurse endoscopists—there are only 20 in Wales. There is a multitude of factors that need to be addressed to sort this issue. 

And there are some health boards that actually perform very well. So, I think, the other bit in this is that it's not that they don't deliver the service, but it's the timeliness of this provision. So, we are very conscious in screening about it being a pathway. So, we're taking patients—well, people—who have no symptoms, we're offering them the test, and then, if they've got a positive screening result, they're then offered a colonoscopy, and that can make them anxious. So, actually, it's the period of time before they get that colonoscopy, then, that we want as short as possible. So, they are getting it, they're just not reaching the timeliness that we would like in order to manage the benefits and harms in the screening pathway. 

Our standards are very, very high. 

Okay. You've inspired, now, a couple of supplementaries. 

Oops. [Laughter.]

So, in terms of—. That doesn't necessarily surprise me, but 18 colonoscopists—

Colonoscopists, yes. 

—sounds very, very minimalistic. So, with Health Education and Improvement Wales, how are you working with them so that we can actually frontload what we need and the incentivisations around that? We know that, in terms of GP training, that is starting to embed and work. And in terms of the nationally directed approach, that's all very well and good, but what does that look like from where you sit—briefly, before I get told off?   

Okay. In terms of the screening colonoscopists, 18 sounds like a very low number, but we do quality assure them very carefully and we need to make sure that they—

But they could, with respect, all burn out next week, if this is the case and we are on a huge programme of improvement. 

Up until this point in time, it's been enough, because we need to make sure they're doing enough procedures to maintain their expertise. So, they have to do at least 80 screening procedures a year. So, up to now, it's sort of been enough.

Okay, but where we're at now in terms of this programme—?

10:15

What we're doing at the moment is actively encouraging health boards to put people forward for accreditation, and we have got a list of people who are happy to go through that process. There aren't a huge number of colonoscopists in Wales who are eligible to do screening because they have to have done at least 750 lifetime procedures; there are criteria they need to achieve. But I don't see that as a massive problem. There are people who are interested, and there are people being upskilled, and I feel quite confident that we will have enough screening colonoscopists.

For the future, I think we do need to be working with Health Education and Improvement Wales, because nurse endoscopists are the obvious way forward. It's going to take some time. Of the 20 we've got in Wales, only three of them currently do colonoscopy, and they don't do it in the numbers that are required to do screening. So, there does need to be a piece of work around that to make sure that we are preparing them for the future screening programme. But I think as a first point it would be beneficial to get them doing more in the symptomatic service to free up the consultants and others who could fit into the screening service.

Okay. So, there's an obvious piece of work there. And in terms of a nationally directed approach—we've had this in a different guise previously—can you briefly outline what that should be?

I think it should be just that: directed. I think the health boards have been through years of collaboration, and there's been an endoscopy implementation group. I think now is the time to actually be more directive in what we expect the health boards to achieve, and I think that needs to start with a very comprehensive baseline review and some systematic demand and capacity modelling in every health board.

I think you've slightly answered it, but I just want to make sure that I totally understand, because I always assumed a colonoscopist was actually a, I don't know, gastroenterologist or some doctor or—. So, is it actually a thing, like being a radiologist or a physiotherapist? Is it actually a—

To do colonoscopy you need to be either a nurse or a doctor. So, our screening colonoscopists at the moment are either gastroenterologists or surgeons. The nurses in Wales are currently doing colonoscopy work within the symptomatic service at the moment, but there are medical and non-medical endoscopists who can do colonoscopy.

And then they undergo, as you say, additional training, and they have to demonstrate that they come into this with sufficient experience and that they maintain a sufficient number of procedures on a regular basis to keep their skills and competency up.

So, it's the continuous professional development programme.

It is. It's an invasive procedure; it carries risks. We need to make certain that the people doing it are absolutely the highest quality that we can get.

That may be the answer, actually. I wanted to pick up what Sharon said about the benefits and harm of the screening programme. I wanted to ask: what is the harm? And I don't know whether that was referring to what you just said or—

Yes. We are always very, very conscious about the quality assurance of the pathway of the screening programme. So, the benefits of the bowel screening programme are twofold. It's to identify people with early bowel cancers and then treatment at an earlier stage before they're symptomatic, because we know that the outcome for that person is better. But the harms of that are that, actually, if you like, we're inviting 290,000 people per year to have a screening test, so, a bowel screening test—actually, there are not a lot of harms in that; it's just not the nicest thing to do. It's not the most pleasant, let's face it. But the main harm in this is that, actually, those who are identified as positive have a wait, they're worried. Suddenly, they've got a potential cancer diagnosis. About 13 per cent of those who get called for colonoscopies will have a cancer diagnosis. So, that's a worrying time, which is why we—

—thirteen—which is why we want it as short as possible. And then the colonoscopy procedure, you have to take some bowel preparation before, which, again, is not the most pleasant thing to do, and the colonoscopy procedure has a very small risk of—sorry—

There's a one in a 1,000 risk of perforation.

—perforation. So, the harms aren't great here, but actually it's the balancing then in terms of the whole population, because we're going to go and invite somebody to that.

So, in very general terms, with any screening programme, the reality is that screening can harm people. It does good, and the whole point is that we implement programmes where we believe that the benefit, the good, exceeds the potential harm. The harm can be in very specific terms, as has been described for a particular programme, or it could be as non-specific as the reality that any test will, for example, identify some people who might have a positive result, but then, on investigation, turn out not—. And we've heard that the identification rate is about 13 per cent, so that's an awful lot of people who we are able to give assurance to, and that's great, but they have been put through a process of concern and anxiety and so on.

The reverse of that, of course, can also happen. Sometimes, a test, however sensitive we set it at, will miss some people who subsequently turn out to have the condition of interest. That then becomes, in a sense, a retrospective concern for the individual who asks themselves, 'Well, how is that that I couldn't have that recognised earlier?' So, these are the things that we have to weigh up, the relative harms and benefits.

10:20

Chair, if I may, very briefly, then. I'm going back to this, and I understand completely the issue around capacity in the system and the pragmatic reasons why the setting is 150. Are we, in any sense, and what analysis is there, of setting that scenario up for quite a few people across Wales in terms of the fact that it's quite a high level of sensitivity of 150, for that very reason that you're saying, 'I've been through that test and now I have a positive result way down the line?' Bearing in mind it's a lot higher than everywhere else in the UK.

Well, we're starting at 150, England will be starting at 120 and we acknowledge that Scotland have already started at 80. Our priority, as we stand here now and look forward, is to implement and then to implement both the reduction in the FIT threshold and the age extension down to 50. And we, as a public health service, recognise, not just with this, but with other programmes, that down the line, looking back, there will always be, potentially, people who've missed an opportunity, and that, I'm afraid, without being too unkind, is the reality.

Yes. Absolutely. Neil, we've partially covered the issue, but the floor is yours.

Okay. Some of our witnesses have suggested that NHS Wales should consider new ways of working to meet the improvement programme for these diagnostic targets, such as regional service delivery models. Can you give your opinion on that? I know you've partly done this in answer to earlier questions.

I think the health boards are working really hard, and they are developing alternative ways of addressing their issues. There certainly are some health boards that are working quite closely with their neighbours. Personally, I think it would be really good for the national programme to look at alternative service models to see how we could best deliver endoscopy services for the people in Wales, and I think they probably will need to think a bit differently.

You were very clear in your earlier evidence that this is a programme that should be nationally driven.

Absolutely. This can only be solved as a whole system. Now, there'll be different ways, and different parts of Wales that'll lend themselves to slightly different approaches, but it has to be part of a whole nationally directed systems approach to the resolution of.

Can I go on to ask whether you plan a public awareness campaign to accompany the national roll-out of FIT and how the pilots in England, and the roll-out in Scotland, provide evidence about the need for this public awareness campaign?

I think, as a programme, we always take every opportunity to raise awareness of the programme, so it will be important that we do have a public awareness campaign around FIT. I think it's also important that we get the timing of that public awareness campaign right. What we wouldn't want to do is for people to withhold completing their original test kit to wait for a new one. So, we are developing a communications strategy at the moment; we're looking at how best we can achieve that. But, yes, we are planning to raise public awareness.

I've been quite surprised by what I think is a pretty low take-up of the option to undertake the screening. I do it myself on a regular basis; I can't understand why nobody else would want to.

We're hoping that the Chair has also—[Inaudible.]

But you're absolutely right; uptake needs to be improved. FIT is obviously going to give us some benefit in terms of improved uptake, it only being one test, and we know from the pilots that it has improved uptake by 8 to 10 per cent. And perhaps the more important thing is that it's also reduced the inequity gap; the gap between the poorest and the richest is reduced with FIT, so that's encouraging, but we still need to work really hard to improve it even further.

10:25

And we're building on quite a few years' experience working particularly with the cancer charities—and you've had them in this morning. We've worked with all of them and we continue to work with all of them on various campaigns to encourage uptake. We've found those really fruitful and we will continue to learn and build together on those experiences as we go forward.

Good. Julie next. Sorry, have you finished, Neil? Yes. Julie, some of your issues are partially covered, but the floor is yours.

Yes. You have referred to the inequalities in take-up and consequently treatment. Could you tell us a bit more about what that gap is and where the inequalities do exist?

We know that the people who are less likely to complete our test kit are men from poorer areas, and the gap between the poorest and the richest in terms of uptake is wider for the bowel screening programme than it is for the other cancer screening programmes, which is a concern, but also quite helpful. We've generated a lot of intelligence over the last few years, so that we now know the people who don't do our test kit, so we're able to target interventions at those cohorts of people. And that's what we're currently doing. So, it is a concern and, like I say, FIT is going to help us, but we're not going to be able to rest assured that that's all we're going to need to do. We've got a lot of work to do in terms of improving uptake.

The work that we've been doing with the charities more recently is quite interesting, particularly the Cancer Research UK study that we did earlier on this year, and that's demonstrated that there's a shift. It's no longer as much about raising awareness of the screening programme, it is about changing attitudes. So, the screening programme is 10 years old now, and people generally know that we're around. There's always some work to do in terms of raising awareness, but this study particularly demonstrated that it is about attitudes and people's reluctance to complete the test kit, so generating some useful information that we can use to plan for interventions.

Again, working with our charity colleagues—and we're working much more closely with them more recently—we need to undertake further research to look at what exactly the barriers are, particularly with men and particularly in the younger age range with age expansion in mind. We don't know a great deal about what's going to affect uptake for the 50 to 60-year-olds, so we need to do some work to identify ways that we can address that issue, but there are other things. Some things that we have done previously that were run as pilots that we found effective haven't yet been implemented and we're working on that this year—things like endorsement flyers sent out three days after the test kits seem to be quite beneficial, so we're planning to implement that later on this year, and various other things.

So, building on the work that we've done over the last few years with our cancer charity colleagues, we're going to be able to implement some of those interventions. But I think the particular piece of work that is going to be really helpful to us is the work with primary care, so working with local communities, with people who actually know the demographics of their communities and are able to advise us on what interventions are likely to work in those groups.

And we'll also learn from the other interventions that we've done across the other cancer screening programmes. So, again going back to Cervical Screening Wales, we're about to shortly run a targeted social media campaign that we've undertaken, again more widely with screening over the summer, and that's using different voices. So, it's not us saying that you will, it's the different trusted people in the community, and very much targeting that, so it's coming through to the population that we want to target, which are the men here, really, from the poorer backgrounds.

We haven't seen evidence of it closing yet, but it's quite difficult. We're quite keen to implement one significant intervention at a time and then evaluate it properly, rather than do lots of things at the same time and not know what's working. So, we've got a carefully worked-out plan of work for the next 12 months and there'll be one significant project undertaken in each area that's evaluated properly, before we move on. So, hopefully, it won't be too long before we can see that there has been an improvement. But, at the moment, we haven't seen the inequity gap reduce. 

But the uptake has shown a general improvement, which we need to keep sustainably, but it's moving in the right direction.

Yes. The last couple of months, we've seen a significant improvement. Obviously, we can't take too much out of two months' worth of data, but we are expecting to see an improvement.

Actually, I just want to ask you a question about endoscopy. We're obviously doing a one-day inquiry into endoscopy services, and the focus is on the prevention of bowel cancer, but, of course, there are, I think, 13 different types of endoscopy out there. So when we look at the—or had references in our previous statements—witness interviews about the 2017 national endoscopy services, and you've made comments about endoscopy services, and some health boards are providing them and some aren't: do you also have any breakdown about whether the gaps are in, say, colonoscopies versus upper endoscopies versus all the other mainly unpronounceable endoscopies that are out there? Because I really want to try and drill down into where the blocks are.

10:30

To coin a phrase. I wish I hadn't said that. [Laughter.]

Obviously, for screening we're only—I wouldn't say 'only interested', but our remit is colonoscopy, so the lower gastrointestinal things. We pick things up because we go around, we talk to health boards, we have a general understanding of what the challenges are. But I think that would be a really important part of the baseline scoping work for this national programme, to look at where the bottlenecks are. My understanding is that the biggest issue is with lower GI endoscopy, but that may not be the case for every health board.

Okay. So, the endoscopy national survey 2017—you're not overly aware of it. I mean, I'm not aware of—

I'm aware of it, yes.

We pick up things. I've read a summary and I know—

I'm going to fire that question at the health boards, anyway—

But again, I think that's got to be the fundamental starting point for the national programme, to do a really comprehensive baseline review, including all endoscopy services, not just colonoscopy.

Because am I right in saying that these, the 18 and the 20 specialists—they will do all of the endoscopies, or is that just 18 and 20 in colonoscopy?

No. The 18 are screening colonoscopists, so they obviously work in the symptomatic service as well, so they do do other endoscopy. They will be doing some upper GI procedures as well, but those are our screening colonoscopists. The 20 nurses will predominantly be doing uppers. Only three of them do colonoscopy, and they don't do colonoscopy for the screening programme.

And then I'm assuming that other things that are very dedicated like arthroscopy—that's probably just with orthopaedics, and they get on with that. So that won't be the endoscopy services per se.

No, but there are some other services that will impact on endoscopy services. There's the hepatology side of the urology. Sometimes they share units. These are all things that need to be considered.

Okay. Happy? Any other questions? There we are. You appear to have floored the membership of this committee, so—

Maybe you could invite us and we'll start again. [Laughter.]

We will leave it there. Thank you very much indeed for your attendance.

Thank you. Nice to meet you all.

And obviously also for the written evidence beforehand. Obviously, as you will know by now, you will receive a transcript of the discussions so you can verify that that actually was what you said, okay. So, thank you very much indeed. For my fellow Members, we'll have a break now till 10:45. Thank you.

Gohiriwyd y cyfarfod rhwng 10:33 ac 10:47.

The meeting adjourned between 10:33 and 10:47.

10:45
4. Gwasanaethau endosgopi yng Nghymru: sesiwn dystiolaeth gyda Rhwydwaith Canser Cymru
4. Endoscopy services in Wales: evidence session with Wales Cancer Network

Croeso nôl i bawb i adran ddiweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. Rydym ni wedi cyrraedd eitem 4 rŵan o'n hymchwiliad i wasanaethau endosgopi yma yng Nghymru—sesiwn dystiolaeth gyda Rhwydwaith Canser Cymru. Ac i'r perwyl yna, rydw i'n falch iawn o groesawu Dr Tom Crosby, cyfarwyddwr meddygol Rhwydwaith Canser Cymru ac oncolegydd ymgynghorol yng Nghanolfan Ganser Felindre yma yng Nghaerdydd. Croeso, bore da i chi. Rydym ni wedi derbyn tystiolaeth ysgrifenedig ymlaen llaw, diolch yn fawr iawn i chi am hynny. Ac yn yr amser sydd gyda ni, awn ni'n syth i mewn i gwestiynau, ac mae Rhianon Passmore yn mynd i ddechrau. 

Welcome back everyone to the latest meeting of the Health, Social Care and Sport Committee here at the National Assembly for Wales. We've reached item 4 now in our inquiry into endoscopy services in Wales, and this is the evidence session with the Wales Cancer Network. And to that end, I'm pleased to welcome Dr Tom Crosby, medical director for the Wales Cancer Network, and consultant oncologist at Velindre Cancer Centre here in Cardiff. Welcome to you, good morning. We've received your written evidence beforehand, so thank you very much for that. And in the time we have, we'll go straight into questions, and Rhianon Passmore has the first.  

Diolch, Chair. Welcome, Tom. In regard to the different thresholds for the FIT test across the UK, the fact that Wales is at a higher level of 150 compared to Scotland and England, do you feel that that is ambitious for Wales, or is it manageable for Wales? And do you think that it's at the right level?  

Would it be possible just to set the scene a little bit for the wider picture of cancer services? It is relevant, because it's around diagnostic services and the performance of the current service. So, what we know is whilst patients have a good experience of cancer when they get into the system and are diagnosed with cancer, we know that other outcomes are not as good in Wales and the rest of the UK compared to other similarly developed countries. We participated in research to understand the reasons—

Sorry, through the Chair, and obviously we know, but for those that are watching, could you say who you are or the 'we' you're using? 

So, I'm talking about the Wales Cancer Network, which is on behalf of NHS Wales cancer services, effectively. Thank you. 

So, the cancer network has worked very closely with something called the International Cancer Benchmarking Partnership, which is a group of developed countries from Canada, Australia, Scandinavian countries to the UK, and it's looked at saying, 'If our outcomes in terms of survival are worse, what are the causes of those outcomes?' And what we think a stage a diagnosis is is very important, and possibly access to care in elderly patients as well. But the modules of that work have looked at the different components of the contributions to why the outcomes may be poor. We know that our patients are not always aware of the signs and symptoms of cancer but, more importantly, we think in Wales they're less likely to act on those signs and symptoms, so, to present themselves to their GP. 

We also know that primary care GPs in Wales are less likely to instigate investigations for signs and symptoms of cancer, and that is in no way a criticism of primary care, with their limited resources and time. What it is is access to diagnostic tests that is putting them off referring patients—

10:50

Sorry, Chair, if I can just ask around that. This has cropped up previously in other areas. So, you are saying that's evaluated. How is that evaluated, and how do you know that it's lack of diagnostics that's making that—[Inaudible.]—rather than lack of awareness?

So, what the cancer benchmarking partnership did was give GPs in all the jurisdictions vignettes. So, they gave them stories of patients with potential signs and symptoms, and they said, 'What would you do on the basis of a patient who's 55, presenting with a cough, or indigestion, or bleeding per rectum?' And in Wales, similar to the rest of the UK, but more exaggerated in Wales, was the fact that primary care were less likely to instigate investigations for those patients. And then, they correlated the willingness of primary care to investigate, given the signs and symptoms, with outcome and survival. And there was a direct correlation between access to diagnostic services and survival from cancer. 

And you may be aware, and others will probably refer to this today, that whilst we do need to do more in terms of awareness of signs and symptoms of cancer, and education of both patients and healthcare professionals in terms of recognition of those signs, a very important paper was published yesterday to say that after patients present with signs and symptoms of colorectal cancer, of lower gastrointestinal cancer, they spend longer in the healthcare system before starting treatment than any of the other jurisdictions. In fact, Wales was chosen as a reference country to compare to other countries. So, we know that, at the moment, the system is not working as well as it can. We welcomed very much the discussion last week around the single cancer pathway, which we'll come on to. So, your original question was: how can we do things differently?

Well, actually, it was directly—and we'll come to that later—around: are we being ambitious enough in Wales in terms of the threshold of 150? And my next question around that, and I'll place it now really, is: quite frankly, is that capacity based, is it pragmatic, and is it system based, rather than patient centred?

We welcome the introduction of FIT per se, because we think it's a better test, it's a more accurate test—it's a quantitative test rather than a qualitative test, such as the one we've had before, and because it's easier to perform, we think that will improve uptake of screening, just FIT in itself. But, no—

It's been set at that threshold to be roughly equivalent in terms of its efficacy as the previous test. And that is on the basis that the capacity in the system is not there to lower that threshold. And we do welcome the announcement that we will, as a system, work towards a lower threshold, although I think it's fair to say, on behalf of the cancer network, who are representing services in Wales, we would want to see that happen sooner than 2023. 

Is there a radical need for a redesign of this system? 

Yes, and I think the system recognises that. I think, at the moment, there isn't the system coming together—and that's Government, NHS Wales, the service—to look at how we sustainably provide greater capacity to meet the forecast demand of the future. Now, the demand has been going up for endoscopy services at about 8 per cent or 9 per cent per year for the last five years, and I don't think, as a system, we've yet to come together to prepare for that incremental change. We now are really excited. This is a cancer that is potentially curable if caught early. We have an evidence-based intervention in the screening services of the use of FIT. That will diagnose more patients at an earlier stage. 

So, I think it is fundamental that, No. 1, we do increase the activity of endoscopy services, but then, in the medium to longer term, we do that in a more sustainable way. And that's got to be via some form of co-ordinated national programme of work. And that's got to look at the infrastructure. It's got to look at the service models—how much do we do locally—

How is that national approach, that directed approach that you're outlining for us now, which is very important, going to take place? How is that shaping up? Is that in situ at the moment, or in the planning?

10:55

It's a little bit in between. We've had an endoscopy implementation group, which has been clinically led, but I don't think has necessarily had the authority and mandate to ensure that things happen—

Well, I think now—

Yes. There is a more directive approach the Welsh Government are taking at the moment, and there's a workshop on 12 December where people are going to come together and look at the issues around how things are better planned for the future, which is about proper, really robust capacity and demand modelling work, then looking at service models of care, but then, at the same time, looking at the workforce and how we build a sustainable workforce. And I think that, at the moment, we'd all agree that that has happened to a certain degree in individual organisations, but not as a nationally co-ordinated programme.

Finally, then, in regard to the age range, the target would be that, by 2023, we are fully encompassing 50-year-olds within that test. Is that also, in terms of our capacity, a sustainable target?

It should be a sustainable and achievable target. It is certainly something that we should be aspiring to, and ideally before 2023.

Coming back to your original question, England are setting a target for FIT, you've probably heard, of 120, and Scotland are at 80 already. I think we should be working more towards that level of 80. But we must put the capacity in the system to be able to turn on the tap a little bit more for people to come more into the system. We shouldn't be afraid of people coming into the system; that's what we've encouraged primary care to do, to refer more patients.

And in terms of achieving those targets earlier, do you think there is scope for that if this new, more directed national approach—?

I believe so. I think we should work as hard as possible to ensure that that happens earlier. So, yes, I think it should. The service would say that we should be doing that before 2023.

This is quite a big question, but you mentioned in response to Rhianon Passmore that there are parts of the service that are better placed in terms of their capacity to achieve what we're setting out to do and to perhaps, as you've said, be able to achieve things earlier. Could you perhaps tell us about what's working well, where? Because it may be that we can learn some lessons from that that could, as part of a more national approach, be rolled out.

I suspect that others speaking today will talk a little bit more in an informed way about the variation in local services. I think that people coming after me will talk about JAG accreditation, and that is a basis for quality of care, but also timeliness of care, and only certain units have achieved that.

What I would say more at my level would be is that the principle should be that, if some parts of a service are working better, organisational boundaries shouldn't be a barrier to patients receiving earlier access to diagnostic tests.

Okay. Angela, I realise some of the issues there have been covered, I think, but the floor is yours.

I think that most of the questions I wanted to ask have been covered, except perhaps the issue of insourcing and outsourcing endoscopy services. Do you have a view on that and its long-term sustainability?

I think that, generically, in terms of diagnostics in the short term, we just need to do more activity, and if that means insourcing work, using various forms of initiatives to achieve that activity, it's the lesser evil. There is no reason, though, why we can't build in Wales our own internally-sourced diagnostic services, both endoscopy and other diagnostics. And I think we have to explore models of work. A group of us went to Denmark to see how their diagnostic systems work, and they have achieved an improvement in outcomes—similar countries, 5 million people, primary care systems, national health service, et cetera. And they have invested in different models of primary and secondary care working together, exploring regional diagnostic pathways and new pathways into diagnosis. So, I think we need to be open to working in those new ways.

Where services, though, are working better in Wales—I'm sure others will say—in Hywel Dda at the moment, they seem to have high-quality, rapid throughput for endoscopy. So, is that something to build on, on that model? So, I'm aware that there are various proposals around regional diagnostic hubs, for instance, and I think we need to pilot, but robustly evaluate how useful those services are.

11:00

Can I ask you a completely random question about the whole issue of diagnostics? Is there a point where you think we don't go back any further? Where should we stop? Where should we stop with calling people forward for diagnostic—?

Do you mean at the risk of over, almost, investigation?

I think we're a long way from that at the moment. So—

Thirty what?

Oh, sorry. Sorry, in terms of age. No. No, I think there's definitely an element of prudency there. We mustn't invite people with a very, very low threshold of having any illnesses. There is something around targeting populations. So, the age of 50 is evidence based. People have talked about lowering the age to 45. I don't think there is robust evidence to support that, but that's probably a direction of travel we'll go to. But if a patient has a family history of cancer, if one of their parents had a cancer at an early age, there is a rationale to looking at those individuals and families potentially five years before that index case. There are genetic syndromes that lead to a much higher risk of colorectal cancer. But, no, I think there's absolutely a risk—we should not be inviting everybody to, at the moment, what is a relatively unpleasant test, a colonoscopy. So, we do need to look at alternative technologies as well to screen this population, and obviously genomics and our gene profiles are things that are going to come through. We're already exploring and piloting in Wales, in Swansea, the use of a blood test to help select out those patients who need the diagnostic tests.

So, there is some sort of diagnostic centre somewhere that says, 'Oh, well, you know, perhaps if you've—.' I don't know; I'm just using—. Because I don't know what the tests would be, but perhaps if you're a smoker, you've got more chance, therefore we'll call smokers forward, or—. There is somebody looking at all of that, is there, and crunching that data?

Yes. I think—. Obviously, the main organisation for evidence-based guidelines is NICE and we follow their guidance, or at least we adopt or justify the following of their guidance. I don't know if somebody else is going to ask, but there is use of FIT not in screening services but in symptomatic patients. We think that will have a useful role, we're just not quite sure of its exact role at the moment. But, at the moment, NICE guidance would suggest referring through for a 3 per cent chance of having a colorectal cancer, even if you have those alarm symptoms of bleeding PR, abdominal pain. It may be that the use of tests such as FIT might be able to triage some of those patients and put them into such a low-risk category that we don't put them through a colonoscopy.

So, you might think—. So, this would be at GP level, would it, would you say, where somebody comes to their GP and says, 'I'm feeling—', 'I've got pain' or whatever it is, and then—?

Well, it's a really good question. I think the tests should be done in primary care, but primary care need the support of secondary care clinicians, because a lot of these patients won't have cancer but they'll have other significant pathology and we can't just leave them in primary care alone to manage a whole new cohort of patients with serious disease. So, I think the test is done in primary care but those tests follow the referral into secondary care, but it may be that those patients are seen and evaluated before going straight to an endoscopic test.

But seen, for example, by, say, a generalist secondary care—

Well, still a gastroenterologist, but not necessarily having a colonoscopy, so—. We've developed the single cancer pathway and there's a lot of work around that and we're really supportive of the announcements made and the investments coming into the service for increased diagnostics. Part of that is to say patients don't need to be—some patients don't need to be—assessed before they go straight to test, but it may be, with the use of a FIT test, if there's more chance of a diagnosis of inflammatory bowel disease rather than cancer, that some of those may not go straight to a test. 

I just wanted to ask—we were told in evidence earlier on that men are less likely to come forward for the test and people from less well-off areas are less likely to come. Have you got any comments about how we tackle that issue?

I think there are various approaches we're trying. We're working with CR UK in terms of they've invested in what are called GP facilitators to come out and have a look at the evidence in clusters and primary care practices to see who is coming forward for screening. We certainly recognise those problems, and, particularly, areas of deprivation that lead to a 15 per cent variation, even in Wales, of uptake.

Yes. So, ranging from 43 per cent up to 60 per cent in terms of uptake and screening tests. I don't think we know the answer, though, to how we change that. Scotland are looking at multi-media messages to deprived communities. So, I think this is an area ripe for research, piloting, evaluation of new practices, but we certainly must recognise that as a really real problem. I think we need to do more research into that area and carefully evaluate. It's very easy to knee jerk to a response of awareness campaigns. They are expensive and we need to do them in an evidence-based way.

11:05

Thank you, Chair. I think you've answered this in part in some of the earlier questions, but I wanted to ask you about the diagnostic workforce and, obviously, the capacity aspects of that. You've said in your paper that it was the shortage of gastroenterologists and non-medical endoscopists that seemed to be the problem. So, what will a future sustainable diagnostic workforce look like, in your opinion?

Well, I think we need to do a little bit more to exactly describe that—what it does look like. I think that, at the moment, it would be recognised that consultant endoscopists, be they gastroenterologists or surgeons, will do endoscopy and will do it very well. Some of them are very experienced and experts in that. But they will also be doing a whole range of other activities as well. Non-medical—particularly nurse—endoscopists are able to commit more time to undertaking endoscopic services. They are a little bit more flexible in terms of their job plans and their timetables about when they do that, and we've shown through quality assurance systems that they can do it just as well as medical practitioners.

What I don't think we have is a national programme of training to get the workforce up to speed to meet the forecast levels of demand. I think we need to do more work around that capacity and demand modelling to say what does a really good service need in three to four years' time to be able to introduce the screening at the right thresholds, to meet the demand that we're putting on primary care to refer these patients through. I think that that can probably only be achieved in a national co-ordinated programme. We look at the National Imaging Academy, and it's probably one of the best things that Wales has done in terms of improving the workforce for diagnostics, and there are some lessons there about how that was developed and how that might work within endoscopy services.   

It's chicken and egg, isn't it? We're going to have this new, improved screening system, which we assume is going to bring an awful lot more people through, but we don't know how many. So, when you want to plan your workforce, you need to have some idea of how many you need. How do you think we might start to address that?

Well, I think it is complex, because, you know, we've talked about predicting forecast demand, and pressures from screening and from symptomatic patients, and lowering thresholds for referral through. We've also talked about some technologies that might reduce the demand on services. But I think we know that, over the next three to four years, demand will rise, likely by 9 per cent, 10 per cent per year for the foreseeable future. At the moment, we do not have the infrastructure, the service models or the workforce to deal with that, and that needs to be a joined-up programme of work.

So, planning for about a 10 per cent increase then, really.

Rhianon, you've got a supplementary on this point.

Briefly, in that regard, then—. So, we're talking again about a national programme in terms of capacity and demand. So, who is liaising, for instance, with Health Education and Improvement Wales and diagnostic centres that you talked about in regard to that training programme? I would like to feel confident that that is occurring so that we can develop the cohort and the capacity across Wales that we know we will need.   

So, I think, at the moment, we—. I think the previous group that was looking at this, the endoscopy implementation group, we felt that it wasn't necessarily having the traction that it required. So, the Welsh Government have indicated that they are leading a more directed approach. And I think—as I say, we are working at the moment towards a workshop on 12 December, and establishing a new implementation group that I think the Welsh Government have indicated that they—

—would want a more directive approach. I can't answer that. But it's very important to work with HEIW. My slight anxiety there is that HEIW are establishing themselves, and I'm sure that they have got a queue of people waiting to get to their door to say, 'We've got workforce challenges here.' So, I think we need to own some of those in terms of the capacity and demand. The Wales cancer network has established a bowel cancer initiative in response to Bowel Cancer UK's report on the problems that we've got in the service. So, I think that we're trying to establish clinical leadership programme management within that, and I think there's something around cancer, the endoscopy services embedding somebody potentially within HEIW to work alongside them, to align, using their methodologies, but to do it at pace for endoscopy.

11:10

We heard earlier that there are about 20 nurses who are trained to be endoscopists, but I think I believe we also heard earlier that, of those 20, almost all of them—I think all bar two or three of them—work in upper gastrointestinal endoscopy, rather than in colonoscopy or sigmoidoscopy or whatever. Do you know what that barrier is that stops them from—? I just basically want to know: are the consultants hugging this and saying, 'No, this is superspecialised, it's got to be gastroenterologists'? Or is it because of health boards not deploying the nurses? Why haven't the nurses been given that upper GI bit? 

Again, I think the people coming after me are probably going to tell you that themselves. Yes, there are upper GI and lower GI endoscopists. I think maybe five, 10 years ago there may have been elements of protectiveness about practices and 'Only we can do this, and only we can do that well', in terms of medical practitioners. I don't see that happening now with the demand on the services. So, I think it's more around having a co-ordinated programme to get the numbers of people training coming through, I would say. But I would defer to others coming after me to say what the problems are—

I just wonder, because you talked earlier about the report that came out yesterday and it showed the pathways—and I'm not going to stray into other people's areas—but I just wondered if it was because, for example, those 20 specialists are only deployed in upper GI?

We certainly need a workforce of non-medical endoscopists working in lower GI cancer as well, absolutely. 

Right, moving on—Neil, you've got the floor now.

I'd like to ask about the urgent suspected cancer pathway. In your evidence, you say that most units are unable to carry out investigations quickly enough to ensure patients are treated within the 62-day start-of-treatment target from referral. Can you tell us a bit more about this and why this is so?

I think it relates to the problems we've already discussed, but the urgent suspected cancer referral pathway is for those patients who do have red-flag symptoms according to the National Institute for Health and Care Excellence guidance, and those patients should be referred by primary care. If in Wales, they are accepted by secondary care as being urgent referrals and not downgraded. They should then, from the time of referral, start treatment within 62 days. And for the more complicated pathways, i.e. those patients who do not have secondary disease early on in the pathway, that is a huge challenge at the moment. And we think the main area is diagnostic capacity and that interface between primary and secondary care. So, realistically, in that pathway, if we want those patients to achieve diagnosis and subsequent treatment by 62 days, they really need to have that first diagnostic test within two weeks. The system is not able to cope with that demand at the moment.

And the introduction of the FIT test should help us to meet that target, do you think?

For symptomatic patients, we need to evaluate it carefully, but in other practices it has been seen to reduce the demand on colonoscopic services, allowing us to meet the timelines for those patients, but also to potentially introduce new demand into the system from screen-detected patients.

Have you got any evidence to suggest that lack of timely access to diagnostic endoscopy services from primary care is having an impact on the way that NICE guidance around referral for suspected cancer is being implemented?

No, I think NICE, in NG12 guidance, has said that there is evidence to support referral down to a 3 per cent conversion rate, so that if 100 patients were referred, three of them will have cancer, and we're not at that rate at the moment. Overall, we're probably at about 8 or 9 per cent of all cancers. So, that is why, I think, the demand is likely to carry on for the next few years while primary care do lower their thresholds for referral.

I see, right. And what about delivering a FIT test at a very sensitive level, say 10 µg in the primary care setting as a stratification tool for those patients with vague symptoms of bowel cancer?

So, basically, there are two areas to do that. There's a group of patients who have non-specific symptoms—abdominal discomfort, no weight loss, no bleeding—that at the moment wouldn't reach the red-flag criteria for urgent referral. And that may be a test for what we say is low risk but not no risk of cancer, where primary care could do a FIT test, set it at a sensitive threshold—possibly 10—that would, if that was positive, put them into a fast-track referral route. The second area is: in those patients who do have alarm symptoms, could we use this to, in some way, triage those patients? But I think it's only fair to say that we need to do that in a careful way and that we don't put the burden of care back onto primary care, because these patients may have other significant disease. So, I think it's something we should be evaluating, and we should do that within a co-ordinated framework, either with individual pilots or a national programme to evaluate the use of FIT in symptomatic patients.

11:15

Okay. Just on the back of that, actually, because obviously one of the huge conundrums we have in general practice is when we have patients who've got a suite of symptoms that are not together enough to tick the red box for an urgent suspected cancer referral, so you end up, as a GP, having to sit on people. You refer them because there's rectal bleeding, but say they've got haemorrhoids that you've found on examination, but also there's something in the story like some abdominal pain or something, obviously, in terms of the urgent USC referral tick boxes, it's not going to tick it, because you've found haemorrhoids and it's rectal bleeding caused by haemorrhoids, but you end up referring for the rectal bleeding, just on the off chance it might be, and then there's a two-year wait. So, in that sort of situation, could you see a situation where, then, we could order a FIT test to make sure that that rectal bleeding actually was down to those haemorrhoids, not down to something else more sinister further up that we can't see in general practice? Is the FIT test sensitive enough, in other words—false negatives, false positives—so that we could use it, arguably, as a screening tool? Because otherwise, at the moment, because USC referrals don't allow for the gut feeling of the GP to intrude on this tick-box exercise at all, and when you think, 'I never see this person, so when they come here, there must be something wrong', as opposed to somebody who is in my surgery every week—but there's no tick box for that with regard to USC. You know, you can explain their symptoms because they've got haemorrhoids, but rectal bleeding is a sign of bowel cancer as well. Now, I've got no means of sifting that out at the moment, and it's not in my nature to be fairly aggressive to secondary care colleagues to insist that they are seen urgently without any USC criteria whatsoever. So, could you foresee a situation where I could use that FIT test, then, so that at least when I know I have to sit on somebody who's got rectal bleeding for another year or two until they're seen in colorectal, I could sort of reassure myself that I'm not actually sitting on an ever-growing hidden cancer as well?

Absolutely. I think this is a really real issue and a really huge challenge, and not just for lower GI cancer. And we know that we have developed a system, because of the capacity of the system, whereby we in fact have a double gate-keeping system. So, we ask primary care to keep people out of hospital at all costs, which isn't necessarily good for diagnosing cancers earlier, and we even have a secondary gate-keeping system where we may downgrade the referrals. And we know that that affects the quality of referrals, because the rapid pathway in is the urgent suspected route, and it may be borderline, but you will try to get them in that route because it's the fast diagnosis, and then you will be shouted at by secondary care for doing it wrong. In Denmark there's the three-legged model, and that is where primary care has access to their own tests for low risk but not no risk, and that's owned by primary care. You do a test, it's a 'yes' or 'no', and the result comes back to you to act on, and, yes, FIT might be the rule-in in that case where you do it. I'm not sure for haemorrhoids—you probably know better than me—but it will pick up bleeding from haemorrhoids as well, obviously. So, that's owned by primary care. 

The other system that we have at the moment that we are piloting in Cwm Taf and in Neath is that vague symptom pathway, where you just feel—your gut feeling, as a GP, a senior GP who hasn't seen this patient before—you just think there's something wrong with the patient, so it's 'Can the secondary care tell me? I think there's something serious.' It may be cancer, it may be something else—it could be mental health illness, frequently, these days. And we're piloting that. We're at the end of the second year. The results are really encouraging. We've got a conversion rate of 10 or 11 per cent for cancer in those. We're evaluating those, finally, next year. So, that is to say to primary care, 'You send people through who you're worried about and we will send you back with a diagnosis. So, I think that's a—that interface between primary and secondary care is a really important one, and those technologies such as FIT will give you the armoury that you need.

We've done an audit in the network to say that, between health boards, there is quite a significant variation in direct access to tests for primary care, even those that NICE recommend that you should have. So, we need to improve and reduce that variation, and we're just repeating the audit now to see if there's been any change. 

11:20

Yes, because there's a sort of mismatch of expectation, isn't there? I mean, I take on board all of the criticism, obviously, that general practice gets in this field, but, obviously, people want an ever-expanding entry for diagnostics. In some parts of England, they're emphasising that patients should just go direct—you know, forget about GPs, just go for the diagnostics, and that's been—. But that cuts across any sort of, I would have thought, pathway development with regard to a single cancer pathway. Are you advocating in that that patients have direct access? Because, otherwise, there's a lot of workforce planning and stuff that is going to go completely—.

Not at the moment. The importance of primary and community care—to know the communities, to know the patients—is vitally important. Eight-minute consultations don't help and the lack of access to diagnostic tests, either your own, by yourself, or in secondary care, don't help either. There had been some pilots of direct access to tests, although I haven't seen any evidence that that is better. That is something where we, possibly, in the future, look at at cluster level, improving diagnostic services closer to you, but I think all those need to be researched, evidence-based and evaluated at the moment. 

Yes, exactly, because we feel a bit miffed in primary care sometimes when people are advocating direct access for people, when GPs haven't got access to MRI scans and stuff. So, how do you expect people to have access to MRI scans if GPs can't get that access? You know, it's one of those sort of conundrums that I always want to throw something at the television when somebody—which is great in theory, but even at gatekeeper level, we haven't got that access. So, actually calling for everybody to have that access isn't going to be helpful, because, as we know, there's a lack of diagnostics in lots of places. 

And we saw this, again, in Denmark, where the same red-flag symptom is a tick box, whether it's blood per rectum or bleeding from another site. There was a study to look at whether the GP actually felt there was something wrong with this patient or they just had that symptom, or there wasn't, and the conversion rate ranges from 30 per cent of the GPs who felt there was something wrong down to about 3 per cent if they were just doing it to send the patient into the system because they'd presented. So, we are dismissing what the GP knows, the experience of GPs, at our peril, I would say.

I'm pleased to—. That, sort of, vague, gut feeling service that you've—. I think that's a very exciting development, I have to say. 

It really is, yes, and it's almost certainly going to become a new standard pathway—that if a GP is just worried, that we see them within two weeks, 62 days et cetera. So, more soon on that. 

I think that's an excellent development. Right, Julie, you're next.

Just on that, are any of these pilots being done in Wales?

Two of them. So, one in Royal Glamorgan Hospital and one in Neath Port Talbot, and we're considering, or most certainly supporting giving them some more money for next year to continue their evaluation of those pilots, and I think then make a recommendation to how they may be rolled out. It may be that they remain as regional models, or it could be that they are just local diagnostic pathways. But, absolutely, the initial evidence is that they are cost-effective, that we're diagnosing people in days, which previously took five, six weeks of going around the houses, and it's been a really, really positive development that we've learnt from another jurisdiction and we've brought back to Wales and successfully piloted it—absolutely. 

Thanks. I was going to ask about ongoing surveillance. Tenovus Cancer Care suggested to us that a number of health boards have insufficient capacity to meet the needs of patients who require ongoing surveillance, where, for example, polyps have been detected. Would you say that that was a true situation?

It is a problem, and it's the same situation around capacity in the service, and, if anything, a patient who's otherwise well—they may have a higher threshold in a way we can defer that test because, 'There's probably nothing wrong with you anyway.' So, we do know that some patients are developing further problems while they're awaiting surveillance colonoscopy. What I would say is that that's the last area where FIT might have a role as well. So, at the moment, the recommendation is to do those after a cancer every three years. It could be that if they're FIT negative, we could extend that out to five or six years. So, it's part of this stratifying patients and doing the right thing to the right patient, not treating everybody the same. So, at the moment, it is a problem in terms of capacity, absolutely. What also should be reported is that whenever a patient does develop a cancer or comes to harm while waiting, that should be reported as an incident, and that isn't being done consistently across the patch.

11:25

Right. So, do we have any evidence from the reporting there has been?

Patients are developing cancers at times—at a low rate—but whilst waiting for surveillance colonoscopy.

Right. Thank you. And then my last question, really, is: do you think there's sufficient ambition and leadership from the Welsh Government to deliver the step change that's needed to improve the early diagnosis?

I'm really encouraged in the last 12 months by the focus that has been placed on what we call the upstream pathway, the diagnostic and the primary-secondary care interface. And I think the statement of intent to lower the threshold for FIT screening, both in terms of age and the FIT threshold, is welcome. I think that, with support from Welsh Government, with committed investment of both existing and new moneys, there is the possibility, with robust system leadership, to do that earlier than 2023. So, I think there is ambition. You know me, Julie, and I think I'd always sort of say that we should have more and we would want to do it more quickly.

Okay. We've got a stage here about the FIT test, and obviously there have been issues about how popular or unpopular the bowel screening programme is in various communities and in various parts of Wales and amongst various age groups. Can you explain for the record the improvement that the FIT test is, compared to the current bowel screening programme situation?

I think the people following me will have the numbers to their fingertips, but we think it'll improve uptake of screening—because it's one test and it's a quantitative test rather than three tests, which were qualitative tests; that's what we had before with the faecal occult blood test—by about 5 per cent just by introducing the test. But others will talk about the proportional increase of the demand from screening, which is still only about 10 or 15 per cent of the demand on the service, and about there being very, very significant increases in that by lowering the age and the thresholds. They've done this in Scotland. They were applauded for coming in at a lower level of 80. They have put the system under a huge pressure, and there are now longer waiting times for endoscopy services in Scotland. So, whether you stress the system—you turn on the tap and hope that the system will cope—or whether you get the system perfect before you switch on the tap, I suspect it's got to be a bit of both.

On that particular point, because this is what we were exploring earlier, which is that if we, in a sense, sound more ambitious but place greater pressure on the system—which, as you have already outlined, in Scotland, has lengthened the waiting list—in a sense, is it pragmatic then to be achievable in terms of our aims? Because if the waiting lists are longer as a result of that lower threshold, the outcome is worse. So, would you say that—I know we've done this once before—in that regard, then: is the balance, as far as patient outcomes are concerned, better in Wales, because that is higher, or not?

No, not at—. I think that everybody would agree that we have set a limit of 150 because we cannot at the moment put more demand into the system. I think we would want to know soon the timelines for a reduction to 120 and, subsequently, almost certainly, lower. That should happen soon, by a commitment of the system to increase the capacity in the system. But I accept that, if we did this—if we just turned on the tap, that would almost certainly be disastrous across the piece—

Absolutely, and all patient outcomes.

Finally, in terms of Denmark, in terms of its modelling and its best practice, how far advanced are they to Wales?

I think they're several years ahead, but not decades ahead. What we've done with the single cancer pathway in the last two to three years, I think, has really put Wales at the forefront, certainly of the UK, in terms of its developments. If we can follow that through with investment and system leadership and turn that around, I think we can go up the league table, both in terms of performance and subsequently, obviously most importantly, of outcomes—one-year and five-year survival—quite rapidly, but if, as a system, Government, health boards, networks and the service come together and deliver those necessary changes, absolutely. I think we are catching up fast.

11:30

Yes, well, certainly, the development of the single cancer pathway is really excellent news. Just one final question from me, unless anybody else has got one: we have, particularly, a bespoke bowel screening programme in this context, and if somebody—because I've got a couple of patients like this—who has had a previous polyp is then in the bowel screening programme as 'under surveillance' and, more soon than usual, they catch it because of that past issue of a polyp, and now they then develop a new symptom like rectal bleeding, which obviously means that, even though it might be benign, with that history, you'd want to see them sooner, but there doesn't seem to be the capacity within Bowel Screening Wales, or within its area of what it's allowed to do, to be able to respond sooner to that situation—we all understand that, obviously—we could use the FIT test then to make sure that that was okay. Or how would you see that developing?

Absolutely. I think it's giving primary care, and to some degree secondary care, the tools to be able to safely manage patients and not allow them to come to harm. But, coming back to the single cancer pathway, whenever somebody, whether it's in primary care or secondary care, suspects a patient of having cancer now, the clock is going to start and those patients will need to start treatment in 62 days, or we'll report that they're not. That allows us to look back at why that didn't happen and the problems you've just described, and to put the solutions into the right places in the pathway to improve the system. 

Excellent. Thank you very much indeed—that was an excellent session of evidence. Thank you very much indeed. I'm looking around, everybody's happy—everybody's deliriously happy. [Laughter.] Thank you very much indeed. You'll receive a transcript of the deliberations, so that you can make sure that they're factually correct, if nothing else. But thank you very much indeed for your attendance.

Thank you very much.

To my fellow Assembly Members—we will break now until 11:45.

Gohiriwyd y cyfarfod rhwng 11:32 ac 11:44.

The meeting adjourned between 11:32 and 11:44.

11:40
5. Gwasanaethau endosgopi yng Nghymru: sesiwn dystiolaeth gyda Bwrdd Iechyd Prifysgol Caerdydd a'r Fro a Bwrdd Iechyd Addysgu Powys
5. Endoscopy services in Wales: evidence session with Cardiff and Vale University Health Board and Powys Teaching Health Board

Croeso nôl i'r adran ddiweddaraf o'r Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. Rydym ni wedi cyrraedd eitem 5 rŵan a pharhad efo'n hymchwiliad i mewn i wasanaethau endoscopi yma yng Nghymru. Mae'r sesiwn dystiolaeth yma gyda Bwrdd Iechyd Lleol Prifysgol Caerdydd a'r Fro a Bwrdd Iechyd Lleol Addysgu Powys.

Mi fydd Aelodau o'r Cynulliad—y rhai craff yn eu mysg—wedi sylwi bod yna rywun ar y sgrin deledu i fyny yn y fan yna, felly, rydw i'n falch i groesawu yn y lle cyntaf Phedra Dodds, nyrs ymgynghorol endosgopi, bwrdd iechyd addysgu Powys. Mae Phedra yma drwy gysylltydd fideo achos mae hi'n cymryd amser allan achos mae'n cymryd rhan mewn viva gogyfer ei doethuriaeth heddiw ar hyn o bryd. Felly, rydym ni yn hynod ddiolchgar am eich ymroddiad i'r ymchwiliad yma, Phedra, a phob croeso i chi.

Welcome back to the latest session of the Health, Social Care and Sport Committee here at the National Assembly for Wales. We've reached item 5 now and a continuation of our inquiry into endoscopy services in Wales. This session is with the Cardiff and Vale University Local Health Board and also Powys Teaching Local Health Board.

Members of the committee will notice that there's somebody on the tv screen in front of us, so I'm very happy to welcome Phedra Dodds, who is a consultant nurse endoscopist at Powys teaching health board. Phedra is here through video link because she's taking part in her viva exam as part of her PhD to provide us with her evidence. So, we are very grateful to you for your commitment to this inquiry, Phedra. Welcome to you.

11:45

The exam's finished, so I'm okay now. 

What, you're saying you're demob happy now, then, is it? There we are. Good. Right.

And here in person as it were, not that Phedra's not in person as well, in front of us, Mr Jared Torkington— 

—cadeirydd sy'n ymadael, Cymdeithas Cymru ar gyfer Gastroenteroleg ac Endosgopi—WAGE, a llawfeddyg ymgynghorol y colon a’r rhefr, bwrdd iechyd prifysgol Caerdydd a’r Fro. Bore da, Mr Torkington. Dr Sunil Dolwani, Cadeirydd newydd Cymdeithas Cymru ar gyfer Gastroenteroleg ac Endosgopi, a gastroenterolegydd ymgynghorol ac arweinydd sgrinio canser y coluddyn, bwrdd iechyd prifysgol Caerdydd a’r Fro. A hefyd Dr John Green, cadeirydd y grŵp sicrwydd ansawdd gwasanaethau endosgopi yn y cyd-grŵp cynghori ar endosgopi gastroberfeddol a gastroenterolegydd ymgynghorol ym mwrdd iechyd prifysgol Caerdydd a’r Fro.

He's the outgoing chair of the Welsh Association for Gastroenterology and Endoscopy—WAGE, and a consultant colorectal surgeon at Cardiff and Vale university health board. Good morning, Mr Torkington. Dr Sunil Dolwani is the incoming chair of the Welsh Association for Gastroenterology and Endoscopy and is also a consultant gastroenterologist and bowel cancer screening lead at Cardiff and Vale university health board. And also Dr John Green, who is the chair of the endoscopy services quality assurance group at the joint advisory group of gastrointestinal endoscopy at Cardiff and Vale university health board. 

Some of the longest job titles in living memory there. A very warm welcome to you all. We've received huge amounts of evidence for this inquiry into endoscopy services, so based on that, we're going to have a fairly intense series of questions over the next hour or so. So, we'll kick off with Helen Mary Jones. 

Thank you. Thank you, all. The sensitivity threshold planned for the screening programme is set at 150 μ here in Wales. It's 80 μ in Scotland and it's going to be 120 in England. Should the Welsh Government be more ambitious with that? Should we be starting at a lower level? 

Thank you. I think there's no doubt that we should have an ambition to go down to the lower level, and if possible in the future, even lower than that. Because for every threshold that is higher we miss cancers that we would have diagnosed. The question is, however, whether we can actually accommodate that. So, I think that the plan to start with the higher threshold may be effective, provided we have a very focused and determined approach to get to the lower level as soon as feasible. 

I think I can take, really, from the way you phrased your answer, that the question of setting the sensitivity threshold where it is about the capacity to deal with it.

So, for the record, I think it's not where it ought to be, but it's the best we can do for now. 

Okay. Thank you. That's helpful. That's a really clear answer. I've been asking that to everybody and I think that's the clearest answer, Chair, that we've got so far.

I agree with Dr Dolwani. He's the expert, and he's very knowledgeable about this. We totally agree with him. 

Thank you. So, looking again—we understand that bowel screening in Wales will screen from the age of 50 every two years and will have a more sensitive threshold by April 2023. So, two questions there. Are we going to be able to do that by 2023? And would there be any scope, do you think, for moving to that position sooner?

If I take the first part of the question first: are we going to be able to do that? We can, provided we change the way we're doing things at the moment. Because what it requires is a lot more people to be trained up to do screening, and it needs that to happen much quicker than it does now. So, one of the things we've put in in our evidence is that this requires a centralised approach where we have intensive training for people in a shortened period of time, which requires both trainees and trainers to be released, and then we can certainly achieve that. 

The second part of it, whether we can do this earlier than that, will depend entirely on how we approach the first part, and the more intensive we can actually be in training people up, and creating the capacity in the system to accommodate it, we can do this.

That's really, helpful, thank you. You're identifying in that answer that the big problem is having enough people with the right skills to undertake the work. Are there any other issues, in terms of—we've had references to physical space, are there the right rooms? Are there questions about having the appropriate kit as well? I think I'm hearing clearly from you that people are the most important thing, but are there some other blocks that we might need to recommend being shifted as well? 

11:50

Indeed, very much so. Infrastructure has been a big problem, because there has not been the investment in endoscopy infrastructure that there should have been and that other countries have seen over the past decade or so. Some examples would be—for example, in Betsi Cadwaladr we have seen two units in really poor infrastructure situations, one where the decontamination room has not been refurbished to the standard that it should be, and another where, quite literally, the roof fell in and endoscopy had to be undertaken in portakabin and mobile van-type situations, which is really unfortunate. This needs a centralised approach to endoscopy investment and infrastructure, so infrastructure, workforce and creating the capacity that goes along with all of that would be quite important as well.  

Rhianon, you've got a supplementary at this point. 

Thank you. How much of an issue is the variation across health boards in terms of endoscopy? The approach in terms of each individual health board.

That has got a number of things within it. I think in terms of approach, the most standardised approach that is UK-wide that should be adopted—and John is the expert on that—is what JAG recommend in terms of how we approach endoscopy planning and how health boards should be doing this— 

Is there an issue around implementation? Because we've heard that health boards have spend, but it's not necessarily the spend that's the issue. So, is there any issue—you've talked about a particular health board there in terms of their approach, but in terms of a nationally directed approach around the whole sector? 

What I can say is that with the nationally directed approach, there has been an attempt to try and standardise the way that demand capacity modelling is done, workforce is looked at, and a look at individual circumstances, for example, in a particular health board, if there are retirements coming up or if there are people who need to be trained up to compensate for that. The attempt is to try and make it more standardised. What is clear is that, of course, there are variations, and there's a lot of variation even within health boards. So, again, I would take the examples of several units within each health board. You can almost see that one unit may function differently from another unit. Some health boards have got a better idea in reducing that intra-health board variation, others less so. And there is, certainly, a lot of variation between health boards. Some health boards seem to have different management structures for each site, which isn't helpful either in actually approaching it in a health board manner. 

So, you would say that there is a need for greater consistency across Wales. 

Absolutely, yes. 

We'll drill down into the details later on. Angela. 

I was listening to your answers with great interest, Dr Dolwani, because Public Health Wales were fairly robust in saying earlier on that they were giving the health boards more than enough money to deliver the current level of screening services. In other words, you've got the money, but you're not spending it on achieving the screening that you should be achieving. Is that a correct observation by them? 

Partly. The reason for that is they modelled the money they gave each health board based on an uptake of a certain level, so at least a 60 per cent uptake, which meant that that percentage of the population would take up screening. And they calculated that, with that number, they would give each health board a certain amount of money.

The second part of that is that if, for example, the same thing, if we look at it in England, a trust is paid per procedure, whereas in Wales we are paid per case. Now, what has happened is, as the programme has matured over 10 years, as more and more people have been diagnosed with either cancer or polyps, more people are under surveillance. So, the level of new people coming in to take up screening has remained the same and lower, so in that way, Public Health Wales are correct that it's lower than what they calculated. But the number of people who've actually increased and accumulated under surveillance has increased more than what they had calculated.

So, what they're saying about health boards not delivering as much as they should have is partly correct, but their calculations were not entirely correct about the surveillance burden on health boards.  

That's very interesting. I don't suppose you happen to have the numbers in terms of how much are we paying for a case to be managed, versus how much, say, for example, in England, they're paid per procedure.  

So, I don't have precise figures but, roughly, for example, a tariff cost for a screening colonoscopy in England might be something like £300-odd per procedure, whereas a health board in Wales would get something close to £750 per case. But that would include not just that procedure, but a subsequent procedure and a subsequent procedure, so that the longer you have a person in surveillance, your actual costs remain the same, but your payment is the same that you had in the initial amount. 

It's a bit more complex than that, in that half the people who come for screening will have a clear bowel, so they will not then go on to surveillance, and so, the health board will calculate its costs according to the other half and take the money that—

11:55

Indeed. 

Okay. And I know that Neil is going to ask a bit more about the workforce, but I did want to particularly ask you, Phedra—. One of the things is that we've got, as we understand it, 18 colonoscopists who are from the surgical side, the medical side, and we've got 20 consultant nurse endoscopists available in Wales. 

No. You've got about 20 nurse endoscopists, only one consultant nurse endoscopist. 

Yes. And only three of us out of the nurse endoscopy community actually perform colonoscopy. The rest perform upper endoscopy or a limited colonoscopy, called a flexible sigmoidoscopy. 

But, then, my very question to you was going to be: why are so few of the nurse endoscopists able or allowed to do colonoscopy?

It's a complicated answer. Part of it is to do with training. It takes a long time to train to do colonoscopy. It takes a lot longer than to do the other two modalities of endoscopy. Part of it is to do with nurses' experience, part of it is to do with training opportunities, and to be honest, part of it is to do with payment. Some nurses are paid less than some others in Wales to perform endoscopy. And colonoscopy is more risky than other procedures, and it's been difficult to tell health boards that, and to actually get a good payment structure for nurses to do colonoscopy. 

Thank you for that clarification because it's come up with witness after witness. 

If I could just ask one final question then. You've just talked about it being more risky. So, how do you feel about the fact that so many health boards—and I'm not sure if Cardiff and Vale are one of them, but we know other boards do—outsource colonoscopies and endoscopy services to private providers, or indeed, this new word I've heard, 'insourcing', where you outsource it, but within your own organisation?

I'll take that then. 

Are we on? Okay. 

So, I have a role in the Royal College of Physicians in London, which Dr Lloyd has explained, and insourcing and outsourcing of activity is endemic across the United Kingdom. It's not a Welsh thing; it's a UK thing. Our survey in 2016 showed that a quarter of UK services, equally distributed across the nations, were having other people do endoscopy, either patients going out or endoscopists coming in. And a number of people in Wales, a number of health boards, have that as a solution to try and improve the pressures they're under by other patients going to local providers, NHS or private, or having people who are accredited endoscopists from elsewhere in the United Kingdom coming to work in their service. 

In terms of the benefits, they should be done by people who are doing that as their day-to-day procedure, both the endoscopists, and the nurses supporting them. So, the safety for the patient should well be there because these are people who are doing that during their normal working week. It requires quite a lot of policing and support from the local health boards to do so because of the amount of work that's generated, and the amount of follow-ups, et cetera, that you need to look at all the pathology reports and the endoscopy reports to make sure that things are done adequately. 

It's not an optimal use of public funding because it's premium rate pay to do so. But it's a solution that the health service across the UK has taken on board to try and improve patient waiting times. 

Yes. I'd like to ask about the workforce. Dr Dolwani said in his evidence earlier on that we need more endoscopists. That's self-evident from the figures, isn't it? So, what does the future endoscopy workforce look like? Are you satisfied that that the health boards have got robust working strategies to deliver the kind of structure that we need?

12:00

If I take the second part of that first: are we satisfied that health boards have got sufficient structures in place to do that? No, we're not. What will the endoscopy workforce look like? At the moment, we're trying to undertake an exercise whereby we do our workforce planning, which is more centralised, and what we also hope to do from the Welsh Association for Gastroenterology and Endoscopy is to make it really detailed, so that every member of staff who's involved in endoscopy can actually tell us about what their level of participation in endoscopy is, what kind of procedures they do, and what their retirement plans are so that we can actually get a really clear idea for the next five years, not just a snapshot for now. That’s something that we hope to know much more about within the next few months, so that we can actually then say, for the first time ever in Wales and in most other areas, 'Here's what we need.' Because leaving it to health boards alone has not resulted in each health board doing this properly at all, and it’s been very reactive and very fragmented.

I was looking at the JAG report 'Endoscopy in 2017', and what interested me there was the figures for Wales of the qualifications of those practising endoscopy. I don't know whether these figures have changed since. I don't know what year they relate to; it doesn't say on the table that I've got. But, in Wales, there were 203 people who were carrying out endoscopy services, and of that number, 165 were at consultant level. I wondered whether this was a sensible use of consultants' time and whether we could have a specialist endoscopy service, which would be more cost-effective and time-effective for consultants.

Yes, I think the traditional model for endoscopy has been very much a consultant-delivered model, and it’s been delivered by a mixture of physicians, gastroenterologists and surgeons who have a whole range of other duties as well. So, there are a lot of pressures with general medicine for the physician side, and from the surgical side with the acute surgical intake and what have you as well—so, pulled in several different directions.

Certainly, most other nations have looked at other models to try and develop the robustness around the workforce that we have, given that a number of consultant posts around the United Kingdom have not been able to be filled, actually, because we're not training enough consultant gastroenterologists. There are a lot of vacancies around. So, we have to think about different workforce models, and the most effective—and Phedra’s done some studies involving this, actually, showing that very effective and valued is a non-medical-based model. Certainly, the English system has developed and rapidly trained a number of non-medical—by non-medical, I mean 'not doctors'; these are predominantly nurses, but they can also be people from other backgrounds, including operating department practitioners, et cetera—for those to develop as a good, effective and reliable, at least diagnostic, workforce. And they’re able to take a number of limited therapeutic procedures as well.

And then your consultant workforce, who are pulled in other directions, can potentially be a group who can develop a lot more around the therapeutic models, the sort of higher risk strategies and things for acutely ill patients that would be with bleeds, those who need advanced polypectomies and what have you. So, yes, I think the workforce is largely going to change, partly because of the massively increasing demand, but also some degree of pragmatism, given the fact that there isn't enough actual consultant workforce across the UK to fill all the gaps that are there at the moment.

I totally agree. I think that, in the future, the nurse workforce will be a lot larger in endoscopy. I think that, hopefully, there will be succession planning. It’s absolutely needed, because of the run-in time for training. In Wales, we do have good nurse training, we do have opportunities for training, we have a very, very good community of gastroenterologists and surgeons in Wales who do endoscopy. We need the health boards to really understand that they need to get on with it now. There’s been a lot of talk about it, but I think there does need to be a push.

Great. Can we have the surgical views, Mr Torkington?

A couple of comments, really. First, we welcome this opportunity to speak to you to give evidence. I think that this is extremely timely. I know time for evidence has closed, but yesterday published in the BMJ was what I feel is probably a new low for Wales, a paper on diagnostic routes and time intervals for patients with colorectal cancer where the statistical analysis uses Wales as its reference point, and everything else within that was, 'How good are you compared to Wales?', or, 'How much better than Wales are you?'

I would say, a couple of points about the discussion so far, cumulatively, certainly between the four of us, we've had over 50 years of dealing with bowel cancer patients on an everyday basis. There is not a week that goes by where we do not diagnose someone with rectal cancer or colon cancer, or tell someone they have cancer, operate on someone with cancer, in my case, tell people, talk to them about the problems that they have. I think that the focus of this group in looking at that is really important. Endoscopy is one part of that, and of course it's important that we don't get confused between screening and the other diagnostic, the symptomatic group.

So, in answer to Helen's point about should we be expanding the age range, of course we should be. It's simple. Phedra is much younger than us, but the three of us have all turned 50 this year, and in 2023 we'll have missed two opportunities to be screened for bowel cancer. In terms of the level, of course it should come down. I have serious concerns that 2023 is just punting it into the long grass and we'll start talking about it in 2022 and it'll get pushed back even further.

So, in terms of the differences between health boards, Phedra has already brought up one point, and that is the differences between how nurses are paid—

12:05

Yes, between health boards. We have the same nurses, doing the same jobs, in different health boards in Wales, on vastly different pay grades. I think that's really important. 

Going forward, endoscopy demand is only going to go up. Every single projection everywhere says it's going to go up. It will have to be delivered more and more by skilled nurses. The three of us are the three people who do screening within Cardiff and Vale. I operate on other days, I do clinics on other days. These guys do ward rounds, they do other clinics, they see other types of patients. We're not just screening endoscopies. We're also part of the surveillance endoscopy group as well. So, we have to expand the workforce. 

The Public Health Wales question is a really interesting one. It's hiding behind accountancy slightly. We know what needs to happen, so let's get it out there in the open and work out the finances properly and be clear with the health boards.

Sorry, Chair. Can you outline to us further—? You know what needs to happen, and we've got an idea in terms of the witnesses that we've had so far. So, outside of some of the things that we've talked about around diagnostics, et cetera, could you outline for us exactly on a menu what needs to happen, and what is your view around system leadership and national direction?

Sorry, before you answer that—because this also goes to one of the hearts of it. I think what you've said has been really, really helpful. We're looking at endoscopy services, and it's the three—the top, the middle and the bottom, essentially. So, why, though, is it so bad when it comes to colonoscopy? What's the issue that's holding up the diagnostic and the surveillance on that level, rather than the upper GI, which seems to have a lot fewer problems? The report that you referred to yesterday, I think it was very much talking about colonoscopy and sigmoidoscopy—if I've got my 'oscopies' right.

Flexible sigmoidoscopy is becoming an outdated procedure. I think I'd go out on a limb and say that. It's half a job in terms of what needs to be done. Gastroscopy, upper GI endoscopy—I don't do any of that really now, but my colleagues may jump in—has not been subject to the same amount of rigour in terms of the quality that we've applied through JAG in the last five to 10 years. What we've—

12:10

The joint advisory group for gastroenterology, which has been—. Well, John is on the executive committee. That has introduced very strict guidelines. In Wales, we have an exceptionally well quality-assured high-level performing screening programme. After that, there is another group of people who do routine colonoscopy, surveillance colonoscopy. They are subject to some of this quality assurance, but not as much as the people doing the screening endoscopy, the screening colonoscopy. The reason that colonoscopy has been so difficult is that: (a) because it is more difficult; (b) because it's more dangerous; (c) because there's quite a therapeutic part to it, such as removing polyps. There doesn't tend to be so much of that from an upper GI gastroscopy point of view. Flexible sigmoidoscopy has been used pretty much as a screening quick-look procedure in the past. So, that's why colonoscopy has become such a focus over the last few years. I don't know if— 

I'm really pleased to hear that because, actually, we couldn't get that answer earlier from witnesses. We were trying to understand if health boards were really aware of where the different problems are within endoscopy services, because it's so obvious that there is that—. So, I completely get that one is a 'look and try and do something about it if you can at that time' and the other one is, literally, more of just a look.

Just to add that I agree entirely with what Jared said. There is a difference in the prevalence and incidence of bowel cancer versus upper GI cancers as well. So, if we look at how gastric cancer incidence has been over the last decade or so, it's pretty much flat. It's not increasing, whereas bowel cancer has been going up and up. You would have heard from people about one in 14 men and one in 19 women, so it is really much more common.

Secondly, exactly as has been alluded to, the training time, the skill required, et cetera, is much more, and it is more than just a diagnostic procedure. The quality standards for upper GI endoscopy have been updated later than they were for colonoscopy by the British Society of Gastroenterology, and that was only last year. We are focusing on that, but it is in the context of which is the bigger population problem.

I almost agree with everything you said, Jared. I think it's a point to say that—[Interruption.] Almost, yes. [Laughter.] I would never say 'totally'. JAG actually oversees the quality of all GI endoscopy, including gastroscopy. The big difference has been—well, there are three or four big differences, adding to your list as well. One is that demand for gastroscopy and flexible sigmoidoscopy has been flat or actually decreasing because of changing modalities of investigation. So, flexible sigmoidoscopy has become less of a demand. Gastroscopy is fairly flat. Colonoscopy has been the biggest expansion. There's a limited number of the workforce who can do colonoscopy. A lot can do the other two. So, you are looking at a smaller group of people, and a colonoscopy takes you at least twice as long as the other two. So, if you are increasing your demand for one modality, it takes you a lot longer to do those than it would to do the other ones as part of your list of activity.

I think it's also important that—. I'm really pleased, actually, that you have mentioned this, because although the focus, correctly, is on bowel cancer and screening, that's less than 10 per cent of our endoscopic activity. The vast majority of the work that we do is not bowel cancer screening. It's done with symptomatic patients whom we get referred from primary care or who present to our hospitals with a whole range of different disorders. So, it's important to recognise that in the context of looking at how we are going to meet the demands for screening.

Just to add to that, and I think you were agreeing with me—[Laughter.] If you look at the screening programme, the screening programme has been running for 10 years in Wales, and it has been hugely successful in terms of the quality it's delivered. During that time, it has diagnosed 2,300 cancers in 10 years. The annual incidence of cancer in Wales is 2,000 cases, which means that, over 10 years, it has diagnosed 10 per cent of the total number of cancers. Now, part of that will be because uptake has not been as high as it should be, and we could have diagnosed more through the screening programme. Part of that is because our age range has not been wide enough. Part of that is about the sensitivity of the test. But, actually, a huge part of it is the fact that the symptomatic service and the surveillance service have struggled to keep up. So, it's very, very important to recognise that for the bowel cancer journey, if you like, endoscopy is a massive part of it. Screening is an extremely important part of it, but it's not the whole picture.

12:15

So, sorry, Chair, from my point, and what we referenced, what then needs to happen, because there's a holistic suite of measures, many of them systemic, and where is the role of leadership in this?

There are a number of things that need to happen—it isn't just one thing. And, if you're asking for a list of things, first of all, there has to be a complete culture change in the way we approach endoscopy services, and although the inquiry is specifically focused on endoscopy services, it is all the things that arise from them—it's pathology, it's radiology, it's the whole diagnostic pathway. And instead of leaving it to a reactive approach currently, which is what health boards do, because the only thing they're held to account for is whether they breach a cancer target or not, or whether they get to a particular endoscopy time target or not, we have to have a proactive approach where we're actually saying, 'We've got enough capacity to absorb all this new technology, reduce our thresholds, expand our age, everything.' So, in order to do that, we should see what did other places do that have implemented this, what did Scotland do. So, Scotland did that—they created the capacity, they did a large part of that through non-medical colonoscopists as well. They implemented FIT in the symptomatic service, and when I speak to them about what we could do, part of it is about creating the capacity to take on the new approach. And both those things have to go hand in hand, because, if we wait for it sequentially, it won't work. And from there spins out the infrastructure, the workforce, and the demand and capacity planning that has to be national. Given the demographic and the size and structure of Wales, it has to be national rather than regional or at health board level.

I think we need to be using what we've got more efficiently. We need to be doing seven day a week endoscopy, we need to be using the suites for 12 hours at a time, we need to have people in them, not just the endoscopists—we need our nursing support as well to be well trained, and have enough of them; I know that some units are struggling in getting enough nurses. We need to have training, we need to have opportunities to progress, and I think endoscopy needs to be seen as a very important speciality within hospitals and within trusts. It is so important on the diagnostic pathway that it just needs to have a much higher profile. 

Excellent. Moving on. Are you done there now, Rhianon?

My question was really about is there a need for a radical new approach, and I think you're actually outlining that we need that.

We do. We do need a radical new approach, because what we're doing is not working. And if you can't get it right in bowel cancer, which is in many ways the most curable of all solid cancers, then you won't be able to get it right in anything else. Because, if you said to me—if you said to me—. If I had to choose a cancer to have myself today, I would have a small, early bowel cancer: have it chopped out, life goes on. That is how benign bowel cancer can be.

So, every week we have a multidisciplinary meeting on a Wednesday morning in Cardiff and we talk through the number of patients that come. And, every week, I circle the ones that are outside the bowel screening age and I circle the ones that were presenting with advanced cancer. So, yesterday morning we had 20 cancers to discuss. Five, so a quarter, were below the bowel screening age. That's just in one week. We have this every week. It's usually a quarter to a third. And then I circle the ones that are presenting with advanced cancer. There were seven, so nearly a third. So, it's no wonder that our bowel cancer survival outcomes are the worst in Europe, because we're not picking up people that are high risk, who've got family cancers.

I'm really delighted that Lynch screening has been agreed, but there's been no implementation date. I'm delighted that we're committed to reducing the level for FIT and screening, but we have punted that into the long grass, to 2023, and we still need to do more in terms of engaging with communities, primary care, community pharmacies, about patient education, public education and awareness in order to get people to present early with symptoms. It does need a radical new approach and, actually, it's no use leaving it to the health boards—it needs some direction from Government.

Just following that—you say it's been thrown into the long grass until 2023. Would you suggest another date?

There is no reason, if there is the will and the willingness, that we can't do this within 18 months to two years. But it needs a commitment to do it. We know—. We've had this conversations several times recently, Phedra, about how long it would take you to upskill people who can already do flexible sigmoidoscopy—an outmoded investigation, in my opinion—up to colonoscopy, and we think we could do it in 18 months. So, the difficulty is how long decisions take to be made. It takes a year for a decision to be made, it takes a year for it to go to consultation, it takes a year for a business case, and we'll be at 2023 before we even know it. So, it needs a commitment, but it can be done. We can afford, in Wales, with a relatively small population with a big black line around it, with dedicated funding, with engaging with the third sector properly—we should be the best in Europe, not the worst.

12:20

Absolutely. A combined approach with the medical community is so important to nurse endoscopists. Anyone can learn endoscopy; we could teach all of you to pop the tube in the right place and wander around, but it's all of those—

I'm not sure about that.

Yes, John, we could. But it's all of those things about critical thinking, teaching nurses how to have almost the gumption to do these riskier procedures, teaching nurses how to think on a more diagnostic plane, being able to give them the support that—. You know, sometimes in endoscopy, especially colonoscopy—as we've said, it is risky. So, sometimes things are going to go wrong, but they need that community around them to offer them the support. None of us nurse endoscopists pretend to be doctors—that's not our bag at all—but we can be trained to do safe, effective, cost-effective endoscopy, and there are lots of us out there. It's estimated that we could do between 60 and 70 per cent of the diagnostic endoscopy out there, and that includes colonoscopy. We need our medical colleagues to do that 30 per cent of really complicated stuff out there, which perhaps is too risky for a nurse to do, needs that extra education and training et cetera, but we can provide a lot of the workforce and a lot of the capacity—if there are enough of us, if we are trained properly, and if there is support.

And the way you've spoken, you feel that you can do it, but I think you said the decision-making process would be too long to enable you to bring that date forward. Is there anything you think we should be recommending as a committee to effect that decision-making process?

I think we'd just say again that it needs to be a radical culture change, which is what I mentioned earlier, and, going back to the very first question that was asked about the threshold and where we should be and our ambition for it, I think there is—. What you are seeing from all of us is that there is no lack of ambition on our part that we should. The question is—we are at a difficult baseline position, and to move from here is not just a matter of an individual colonoscopist being trained; we want it in enough numbers, and that needs a big shift in the system to enable us to achieve that ambition. That's the difficulty here. In a way, what you will have heard and will probably hear from other parts, including Government, Public Health Wales, et cetera, is what those structures feel they can achieve. It is only through moving that very radically that we can actually achieve that ambition, and I think it's going to be extremely challenging to do it otherwise.

Yes, it's just a quick question about is there a clinical level of how many colonoscopies you have to be able to do to maintain your continuing professional development, and, when you say that you could do it within 18 months, to bring nurses up to speed to be able to do this, would that only be in certain parts of Wales where there is enough population mass to be able to do the number of procedures that you would need to do to become qualified?

No. Even in Powys, where we have more sheep than people, we have lots of people needing colonoscopy. We could do it every day. As has been said, the need for colonoscopy is just going up and up and up. We're anticipating another double in demand for colonoscopy in the next five years or so. You can train these people anywhere.

Okay, and is there a number—? Is there a number that you have to have—you have to be able to do—to be qualified?

The number for training—at minimum, you have to do a couple of 100 colonoscopies at least. But, in actual fact, that just gets you across the line to say you can do a safe colonoscopy. In order to do a colonoscopy that is going to be of value beyond just being a safe colonoscopy, there is a lot more required. To become a screener—for example, a screening colonoscopist in England, you would have to have a lifetime number of at least 1,000 colonoscopies. In Wales, we relaxed that, because of having a younger consultant workforce, to 750 lifetime colonoscopies. And that is the minimum level of experience you need, because you want to be safe, you want to be experienced, you want be able to interpret what you see and not just do a technical procedure.

12:25

Chair, if I may ask Phedra, if it's relevant—? We've mentioned that pay structures are very different for you across Wales. How important is that to trainees who wish to be going down this particular route, bearing in mind the levels of difficulty and risk that can be involved?

I think it's very important. Currently in Wales, most nurses are paid—to do endoscopy, they're paid the same as a ward sister. So, traditionally in nursing it's been seen that anything above that in terms of pay grades—so you'd be looking at the 8s; 8A, 8B and 8C— would just be for management. But I'm a consultant nurse, I don't do any management, I'm a clinician, I'm a diagnostician, and I get paid an 8B. And I believe that nurses doing endoscopy are as skilled, if not more skilled in certain areas, and 8A is the minimum that they should be paid.

So, that should be reviewed in terms of a systemic approach to change. Do you think that should be—?

It has to be.

No, I haven't finished. I think you said when you were giving earlier evidence that JAG has strict guidelines and high-quality standards. Just for me to understand, the accreditation of endoscopy units across Wales—is that done by JAG?

I will defer to John, but I will say that I have read some of the other evidence that's been given to the committee. One of the things that we seem to be celebrating is that we've got six units in Wales that are JAG accredited. We have 20 units in Wales. Of those six that are accredited, there's only one, which is Bridgend, that is in a busy metropolis, and the others, if Phedra doesn't mind me saying it, given that she works in Brecon, are in more rural areas, with a little bit more control over what's happening in their institutions—

No. But John will tell you more about the accreditation process and where we are in Wales with it.

I'll try and contain myself to a brief answer. So, JAG is a multi-collegiate group, formed with the Royal College of Physicians and the Royal College of Surgeons, formed over 20 years ago, initially just to focus on training for endoscopists, so it's an important part of that, but, with the introduction of bowel cancer screening in England, they developed a service to accredit units, and that's now in place across all nations of the United Kingdom. There are about 22 different standards—aspects of patient care—that you accredit against, so it's all from the quality, the safety, the timeliness, the appropriateness, patient feedback and then aspects of the workforce, the training and the environment. It's a holistic approach to endoscopy. If you're a JAG-accredited unit, you can be assured to your patients, to your staff and your public that you have an optimal service, that you're delivering the best that you can do. It's done by a service providing evidence from their documents, their audits, their waiting lists, their processes that they're doing everything right. There's a whole load of evidence requirements that JAG requires, and then there's a site visit—and I do assessments myself—where we go in as a clinical lead, a nursing lead, and a managerial lead and a layperson as well to make sure that the service is optimally delivered.

In Wales, we have an agreement that we have a level 1 and level 2 accreditation system, because we recognise that the aspects you've heard this morning—the two major constraints are around some of the environmental issues in some of our units and the timeliness, the waiting list requirements. In Wales, we require a two-week wait for cancers and urgent patients and eight weeks for routine and surveillance patients. In the level 1 agreement, which was like a stepping-stone to full accreditation, we have relaxed the waits a little, and we've let people do what they can do with their environment with the support of their health board to put a signed-off agreement to do the necessary building work that's done to optimally do it. At the moment, we have, as Jared has said, six out of 20 units that are accredited. We've had ministerial letters and we've had pressure put on the health boards to become accredited, and the three of us actually attend the national meeting, an endoscopy implementation group, where that progress is reviewed. But the major stumbling block, still, is the timeliness aspect and the environment aspect. But if you want to know that a unit is good, look outside them and see if they've got the JAG accreditation—you'll be sure that they are. We have an awful lot of very, very good units in Wales, including the unit that I work in, which we can't get accredited because of the issues with waiting times, but we know that we've got everything else in place.

12:30

I think you've answered my question already about future planning. I was going to ask you about leadership and what needs to be done, and you've already said a major cultural change—a step change, really—so, I won't go back on that. But I just wanted to ask you very briefly about symptomatic patients and the introduction—I think, Jared, you may have touched on this earlier—of FIT testing as part of the primary-secondary care pathway for symptomatic patients. And there seems to be some evidence that that would be useful, but I'm guessing that the failure, really, to use that and to introduce that to any great extent is a capacity one again. 

Essentially, it is a capacity one—everything comes back to capacity. The evidence base for symptomatic FIT is emerging, and it may be symptomatic FIT testing now—next year, it may be a blood test, or the year after that, it may be a breath test. These things evolve, of course. The concept of having something for GPs to use to stratify risk, if only to be able to say, 'I think they should have a colonoscopy, but I don't think it's urgent' or 'I think they should have a colonoscopy—I think it is urgent' is a really useful tool. And we know that, because of the routine waiting list for colonoscopy, GPs game and we game in order to make sure that patients get done in a timely fashion, rather than waiting an awful long time.

So, the difficulty we have with symptomatic FIT is that it will put more pressure on a system that is failing. I think I speak for the three of us, and, in fact, most of the community that deals with these patients—we all want to see more tests in primary care that can somehow reduce demand and give GPs the confidence not to refer everybody they see, not to feel that they're making the right decisions in terms of that, but we are conscious that the evidence base at the moment is emerging. We think that Wales is perfectly placed to be trialling and collecting evidence to support the widespread introduction of this. Health Technology Wales is currently doing an examination of this. Whether it will give us the right answer or not is difficult, because they're looking at it within the context of bowel cancer prediction, not just as a stand-alone test, but I think there are quite advanced plans for trialling it.

This is what they've been doing in Scotland, is that right?

Yes. It is what they've done in Scotland, in Dundee, Tayside, particularly—not all of Scotland yet—and they are rolling it out in other areas. Just to add to what Jared said, the specific plans—what we want to do is not give yet another overly complicated pathway to primary care colleagues, in a time-pressured consultation, to have difficulty in referring appropriately. We're trying to simplify it and keep it as evidence based as possible, and what we're trying to do is pilot it and trial it and see the impact of it, because the centre of all this has got to be the patient. A lot of this is not about how it reduces the demand on colonoscopy; it's about how we diagnose cancers earlier and what happens to those patients, because a patient has come to a GP with some symptoms. The Scottish approach, which we don't completely agree with, has been, 'If  you don't have cancer, off you go, look up on the internet about your symptoms'—that type of thing. I'm being a bit broad and crude about it, but it's: 'If you don't have cancer, don't worry about it'. Whereas the patient—they need some resolution of their symptoms as well. So, they may then, by a different route, come to us in clinic, for example, and so, although we're reducing the pressure on one part of the system, we may be increasing it on a different part of the system. What we'd like to do is have a very clear idea of what it will mean for the system before we completely roll it out.

12:35

And—sorry, before you come in—what is the evidence that actually exists that it's useful in symptomatic patients, or that it could be useful in symptomatic patients? 

There is good evidence that it can help you stratify those at higher risk compared to then just looking at symptoms alone. 

You have to remember that, of course, there are patients with other diagnoses—Crohn's disease, colitis, patients with polyps—and we have a tendency when we get into conversations about bowel cancer and talking about endoscopy that if we only pick up 3 per cent of them having a cancer, then the 97 per cent are a waste of time, but, actually, it's quite important in terms of reassuring people, it's quite important in terms of removing polyps to prevent bowel cancer, and it may be important in picking up other diseases as well. So, we must be careful, because bowel cancer's so common, because we talk about it so much and because we're doing so badly at it, that we don't forget that, actually, colonoscopy does have a role in the non-cancer patients. 

Yes, and the FIT test wouldn't pick up those things. 

The FIT test will pick up a lot of those patients.

It will pick up those things as well. Okay. Sorry, you were going to—

Yes, anything that bleeds, basically. The presence of blood helps you risk stratify. 

Yes, which actually—. I was going to ask you what your view was on the colonoscopy service. If you do a colonoscopy and you find that somebody doesn't have something that's within what you would deal with, but you can see that there is an issue—so, for example, perhaps blood is coming through the small colon, or the ileum or whatever, so therefore there is another issue of being able to then refer them directly to that bit of the service, because from what I understand, from what I hear, people are then told, 'Our bit is ticked—you're okay. You have to go back to your GP. I suggest you ask your GP to then refer you to this service for an upper GI, or to this service because we think you might have colitis'—or Crohn's or whatever. 

It's unfortunate that that is still happening in some parts of Wales, but, actually, there are good national guidelines on how to deal with that— the British Society of Gastroenterology guidelines on how to deal with someone with anaemia who might be bleeding from somewhere, and there is a standardised series of tests that we need to do. We need to do an endoscopy or colonoscopy, check the small bowel if we haven't found anything with the wireless capsule endoscopy—if we don't find anything there, then check that there's no problem with the kidneys, check the urine. That is very standard. 

The unfortunate part of it, though—from a professional guidelines point of view, which are very clear—is that what individual health boards might be doing is that they are saying, 'Go back to the GP. This was just for this procedure'. And, again, what it needs is a very integrated approach—that the patients come to us and we need to sort everything out for the patient—rather than this dichotomy of, 'This is primary care responsibility' or 'This is secondary—'. It's all our joint responsibility. It has to be far more integrated, which is the reason why we want to pilot FIT differently. One of the things that's come out of pilots in England is that just saying to a GP, 'Here's a test result' does not really necessarily increase the way the patient's going to benefit. It's about the help, the support, the education and training and the pathway all working together so that the test can have it's best possible use. It's not in isolation.

Okay. Dawn, are you done? Excellent. I think that's the end of the session. Excellent. Can I thank you very much indeed for your attendance, and Phedra—amazing performance there from deepest Powys? Thank you very much indeed. 

I'm in Swansea.

There we are. Good stuff. Lovely. Thank you very much indeed. You will all receive a transcript of the deliberations so you can correct things that need correcting—factually or whatever. But thank you very much indeed. 

Thank you.

Thank you.

And can I announce to my fellow Assembly Members now that we will break for a short luncheon period and we'll be returning by 1.15 p.m.

Gohiriwyd y cyfarfod rhwng 12:39 ac 13:16.

The meeting adjourned between 12:39 and 13:16.

13:15
6. Gwasanaethau endosgopi yng Nghymru: sesiwn dystiolaeth gydag Addysg a Gwella Iechyd Cymru
6. Endoscopy services in Wales: evidence session with Health Education and Improvement Wales

Croeso nôl i bawb i adran y prynhawn o'r Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. Rydym wedi cyrraedd eitem 6 rŵan, a pharhad efo'n harolwg i mewn i wasanaethau endosgopi yma yng Nghymru. Rydym wedi cyrraedd sesiwn dystiolaeth rŵan efo Addysg a Gwella Iechyd Cymru, ac i'r perwyl yna rydw i'n falch iawn i groesawu i'r bwrdd Dr Neil Hawkes, gastroenterolegydd ymgynghorol gydag Addysg a Gwella Iechyd Cymru. Rydym wedi derbyn eich tystiolaeth ysgrifenedig fendigedig—diolch yn fawr— ymlaen llaw, ac yn unol â'n traddodiad, awn yn syth i mewn i gwestiynau. Mae gyda ni ryw hanner awr. Mae yna nifer o gwestiynau cryno, wrth gwrs ac, yn naturiol, fe fydd yna atebion cryno, gobeithio. Helen Mary Jones. 

Welcome back all to this afternoon's section of the Health, Social Care and Sport Committee here at the National Assembly for Wales. We've now reached item 6, and a continuation of our inquiry into endoscopy services in Wales. We have reached the evidence session with Health Education and Improvement Wales, and to that end I'm very pleased to welcome Dr Neil Hawkes, consultant gastroenterologist with Health Education and Improvement Wales. We have received your written evidence—great evidence, and thank you for that—beforehand. As usual, we'll go straight into questions. We've got about half an hour and a number of questions—brief questions, naturally, and, naturally, there'll be brief answers. Helen Mary Jones. 

Diolch, Cadeirydd. Thank you, Dai. I know it's early days, so there may be some 'we're working on it' answers, and we fully appreciate that. But can you outline for us the relationship between Health Education and Improvement Wales and the local health boards, and the way in which you are supporting local health boards across Wales to expand their diagnostic endoscopy—I can't say that—workforce to meet the capacity challenges that we all know are there? 

I think I should make it clear that I don't have a formal role with Health Education and Improvement Wales at the current time, but I am advising them. So, the qualifications I would have for that is that I have been the clinical lead for the Welsh endoscopy training network for the past 12 years. I've also chaired the joint advisory group on gastrointestinal endoscopy on a UK-wide basis in terms of their training committee.     

Thank you. So, the question about how you're going to work with the—well, how Health Education and Improvement Wales are planning to work, with your advice, with the health boards to address these workforce capacity issues.  

The written submission that was given to you was to try and provide a strategic overview for what the training requirements would be, and to also break down the different components of the workforce. The endoscopy workforce is quite complex, and constitutes consultant workforce, staff-grade workforce, endoscopy nurses et cetera. The other important thing, I think, is that different health boards have different constitutions of those staff members, and I think one of the key pieces of work that HEIW will need to do is to understand in much more detail exactly who is contributing to their workforce, so that we can plan out their training appropriately to improve the quality of the colonoscopy they're providing and, of course, centrally, the capacity requirements that they're going to have and how they're going to increase that in a timely way. 

Okay. Again, you may not be able to fully answer this, but does HEIW have, as yet, a picture of what the current vacancy rate is for those different workforce groups that you've just mentioned in endoscopy services across Wales? 

I don't think it has accurate data, no. 

It doesn't. And to what extent do you believe that the issues that there are in filling vacancies are due to a UK shortage of available trained clinicians, or is this more of a problem for Wales than it is in other parts of the UK?  

No, I think the capacity issues have hit every endoscopy unit in the UK. The workforce that is then required takes time to train up, and so health boards and trusts across the UK are having to look at where they get their staff from. And the choices are: you appoint more consultant staff, or you look at nurse endoscopists as a workforce, or you look at who else could do endoscopy, and there's a broad range of other people now involved—acute care physicians are contributing; radiologists have traditionally given some involvement. So, you can look across your entire workforce to see who might have the skills to learn endoscopy. It doesn't really matter which group you pick. The key is that that group are then trained to do highly effective colonoscopy. 

13:20

Can I just pick up on that point about who else could be trained? Of course, the evidence we've had so far today has been very much around gastroenterologists doing it, and nurses. So, I was really interested to hear about the acute care physicians and radiologists. What other sort of groups might you identify as having that possibility of being trained up?

Wales has a very strong tradition of radiologists being involved. On the technique of endoscopic retrograde cholangiopancreatography, which looks at bile ducts—Lawrie was one of the founder members of the group that invented ERCP. So, he bred a group of radiologists who are very good endoscopists. So, I think we need to think outside the box a little bit from where we have traditionally had endoscopists from. I think the key—. From a UK perspective, the joint advisory group have set out very clear guidelines about how the training should run and what criteria you should achieve to get certification. 

Yes, there'll be more detailed questions on that now, in a minute, but carry on. 

So, provided somebody puts themselves forward, and is prepared to go through that training pathway, then I think we should have a broader view as to who we're looking at, and, obviously, a key question is the timescale in which they can be brought through those training pathways. 

When you answered Helen Mary's questions, you mentioned the fact that there was a workforce shortage in Wales and the UK. Given that workforce shortage and the comments you've made about how long it takes people to train up, do you think that there will be enough people in place to be able to meet the Welsh Government's 2023 target for the screening programme?

I think it's a challenge. My comment would be that we have to start right away in identifying those people because it's going to take, for colonoscopy, 12 to 18 months, even if you put in place accelerated training programmes, to get people through. And the experience from the Health Education England programme of selecting nurse endoscopists in England was just that the logistics of going out to the trusts or health boards, finding who they would want to support to go through these pathways, interviewing them and preparing them for the training—that takes another few months as well. So, I think we have to be smart and on the front foot with this. 

And as Health Education Improvement Wales, do you look at those workforce gaps? Who feeds you that data? Do you just look at it because you think, 'We've got to try and monitor all of our workforce issues across the whole piece', or do you react to health boards coming to you saying, 'We've got a gap—we can't provide endoscopy services because we haven't got enough people'? Or is it more that Welsh Government will produce an initiative such as this one, where we have targets by 2023, and then you react to that? I'm trying to understand where the data is out there and how you get hold of that data, what ownership you have of it and how you cut and slice it to decide where the holes are, how you fill them in et cetera.

I think anybody who does workforce planning knows it's complex. I think that we can move quite quickly to survey health boards, but it needs to go deeper than just the numbers of people who are physically in post. What you've got to understand is what they do on a day-to-day basis—the exact details of their job plan—because there are different ways that you could liberate endoscopy sessions from existing workforce. There are also then the options to bring new people through. I think we need to explore both those things, and different solutions may fit different health boards. So, I think we need to be actively pushing health boards to look at the fact that they’re going to have to increase their capacity, and then we need to help them to address the difficult questions of how and who, how long they will need to be trained up, and then, in my view, we need a central support to help with the education of those people, so that they can reach the required standards as soon as possible.

13:25

Health boards are notably intransigent. We know Welsh Government itself will weep tears sometimes because they can’t get a health board to do what a health board should do. How much welly do you guys have behind you to actually get the health boards to go out there, do these surveys and come back with meaningful data that you can then prepare people for?

That’s a very good question. I think my previous answer suggested that there has to be something in it for them, but if you can identify the people who need training—. And what HEE did in England was they then paid for their training programmes, and what the health board is then getting is somebody who is fully trained up, who can then hit the ground running and deliver endoscopy. So, I think it's a bit of a quid pro quo, and if the health boards can see that there is something in it for them, they’re more likely to assist.

So, our last question to you is one of these, 'Here's a piece of string—'. [Laughter.] So, we know that we've got 18 or so endoscopists, who come from the surgical gastroenterology route. We’ve got 20 nurses and one nurse-consultant endoscopist. Do you have any feel for how many we are likely to need of a multidisciplinary team around the whole endoscopy services, particularly colonoscopy, which we’ve learnt today is a more complex process than, say, an upper GI endoscopy? Do you have any feel for how many people we're likely to need by 2023 to meet the targets as they are set now? And even more pie in the sky, would you be able to give a feeling for—if the boundaries were pushed out, if the ages were really extended and if we had much more involvement with primary care—what that might result in, in terms of numbers? Are we doubling our workforce—tripling it?

Too many blue-sky-thinking questions, probably. I think the—

I said it was a very long piece of string. [Laughter.]

It was a long piece of string. We must be planning on the fact that, over the next five years, we will probably need to get at least 50 per cent more endoscopists through programmes. Obviously, I’ve just intimated that we don’t have the granularity of the workforce that we need, but—

Sorry, but could you explain that phrase—'granularity of the workforce'?

It's the very fine detail of people's job plans. The other thing that you need to be aware of, and this comes back to the history of how endoscopy has developed as a service, is the fact that you've got so many different specialities contributing to it, and they all have very different other parts to their day job, and we need to look seriously at who should be the professional groups that do deliver colonoscopy. I don't think it's going to matter necessarily which specialty you come from, but I think that if you do colonoscopy, there's very good data suggesting that you've got to be doing more than 300 colonoscopies a year to get up to the very high-quality standards. And this matters because it's linked to your performance outcomes, and we have too many colonoscopists in Wales at the moment who are doing nowhere near 300 colonoscopies a year, and that matters because of the quality. When you're thinking, then, about cancer statistics and cancer outcomes, having a detection rate that is only half of another colonoscopist matters. So, I think it's an opportunity to really look at our workforce and make sure it is fit for 2025.

13:30

Yes. You've mentioned liberating staff into endoscopy and pushing health boards, and you've been quite careful, I think, with your responses. So, with regard to the cohort of nurse practitioners out there—one of whom we heard earlier on this afternoon—one of the issues that was brought up was actually pay structures and variances across the health boards. Obviously, you've mentioned incentivisation in terms of in England paying for that endoscopy training, but in terms of retention, then, later on, is it of any merit that we actually try and standardise pay structures around endoscopy across Wales in terms of nursing practitioners? Because obviously it's not going to be—in my view, anyway—helpful if it's so varied. What's your view?

I think that can only help, and I would extend that to looking at the workforce structure of endoscopy nurses who assist the procedure. We have a big problem because we have a lot of band 5s and maybe one band 6 and one band 7 within a unit, and there's no way that these girls can progress within endoscopy, so they leave endoscopy, and it's a massive haemorrhaging of skilled people who we need to keep—

I think we might like to point out that we might have some boys doing that also. [Laughter.]

But in terms of this substantive issue—support staff as well, in some of the units, was actually mentioned earlier as well—would any sort of review of that structure be of any merit, do you think?

We've got right to the end of the questioning, have we, or have I got the wrong—? Sorry, I'm on the wrong page. 

Yes, that's right. Sorry, I was looking at the wrong page. JAG provides accreditation standards for endoscopy units and certification requirements for individual endoscopists. Is there a national endoscopy training strategy in place that sufficiently prioritises the training needs of endoscopists and matches the requirements mandated by JAG?

JAG are actually in the process of updating all of the training pathways. So, they regularly look at the certification elements. I think the UK has probably one of the best defined training structures in the world, and it certainly is something that other countries look toward with jealousy. There's been a lot of published work over the last two or three years from the JAG, providing evidence for the competency assessments that are performed on individual endoscopists, and they are looking to try and ensure that trainees are supported as much as they possibly can be. For example, we're just in the middle of looking at a national structured course for training people in controlling bleeding emergencies. So, a group of training leads will come together, they will look at the current evidence base, they will produce a core set of training materials, and then that is run as a pilot course and then standardised so that, whether you're doing your endoscopy training in Bolton, Brighton or Bridgend, you will get the same package of training. That's really important for quality assurance and standardisation of care. 

In your paper, you say that investment in training infrastructure for endoscopy is badly needed. There's been no central funding given to this since March 2009. Can you provide an estimate of the level of investment that you think might be needed to replace the outmoded training equipment and to upgrade clinical training centres for endoscopy to meet JAG quality assurance standards?

I think it depends on the level of ambition that we have, but I think, if you're going to try and target all of the different workforce groups and get them through, you're looking at a similar kind of investment to that which has already been made in the radiology imaging academy.

13:35

Right. I was quite surprised, when I looked into the background of this, to see that about three-quarters of the endoscopists are actually at the consultant grade, which is obviously a very senior medial grade. If we are going to vastly increase the number of endoscopists, or the number of people capable of carrying out these procedures, that proportion simply can't be maintained, can it? So, we're going to need to change the whole structure of the endoscopy workforce. 

I think you will. It's also worth reminding you of the fact that, again, coming back historically, this kind of advanced training in endoscopy only came in around 2000, and the reason for it was that it was—. Mike Richards, in England, commissioned an audit to look at how good the colonoscopy services were in several places in England, and got the answer back that the completion rate was about 57 per cent, which was a disaster when they were trying to think of implementing a bowel cancer screening programme. The latest UK audit has shown that, across the UK, we're now getting completion rates of 90 per cent, so you can see the level of improvement. A lot of that improvement was attributed to the introduction of training programmes between 2000 and 2010, but some of our older consultants didn't have that training. I think it's an important part of their revalidation cycle. If they're committed to doing endoscopy, we should be providing them with CPD opportunities to keep up to date with their skills, and that's one of the important roles of a central academy or whatever you want to call it.

You've talked, in answer to Neil and somebody else, about radiologists, perhaps—I think it might have been me, actually, who asked that question—radiologists and nurses and so on. Would there be a reason why we couldn't have endoscopy as a career on its own? The reason why I ask that is that you said you've got to do at least 300 a year, so I tried to work out in my head—not successfully—how many hours a year that would be. I would imagine that that's going to be pretty much a full-time year. So, we have radiologists, we have physiotherapists, we have other 'ists' who specialise in something. Would we ever see endoscopy going down that route—that we have endoscopists?

Well, by default you've almost got them. So, for example—

You are HEIW. So, it's a, 'I want to grow up to do this job' and, you know, you go in as a career and you learn all the things around it.

I'm a gastroenterologist first, so in my job plan that I do, I have five or six endoscopy sessions in a week. So, that's two-thirds of my time. The reason why people would be limited in doing more than that is that it's very physical. So, if you're doing a colonoscopy list for three and a half hours, it's hard work. People get shoulder injuries and repetitive strain injuries. Obviously, they can do other roles in some of the other sessions, but the advice generally—and this would pertain, too, if you were training nurse endoscopists as well—is that, probably, the upper limit that's advised is about five sessions. So, it's half a full-time job, actually doing the physical act of colonoscopy. That's just because you have got to make sure that people stay fit and healthy. It has an impact on retention, actually, because if somebody is feeling that they get home and their shoulders are aching and their back is aching, they may do it for a little while, but then they won't do it anymore. 

Okay. Final question, Rhianon—it's been partially answered—about more blue sky thinking and the academy. Radiologists have got one, so go on.

It's just really a question around the benefits of a—and I think this is the key word—centrally supported endoscopy academy. But, further to that question, really, is: what is your view in terms of the journey that we are approaching in terms of, you know, the current situation around the FIT tests and the capacity issue? Are we on the right track? And, in your view, if it's possible to do it succinctly, what needs to happen? I know you've mentioned a few things already, but if you could—?

13:40

So, I think colonoscopy is still your best weapon in tackling bowel cancer. It, therefore, needs to be delivered well, and a bowel screening programme is important and we should be proud of the BSW programme, because it's delivered high-quality outcomes. The concern is that that only represents 10 per cent of what colonoscopy is going on and, actually, small improvements in the 90 per cent of colonoscopy that goes on on a day-to-day basis are just as important to the overall outcomes in Wales for bowel cancer. 

So, you're adding, in a sense, the fact that there needs to be much more of an emphasis, in a sense, on continuing professional development across the piste—it doesn't matter what age or expertise you have—but also in terms of qualitative assessment.

And that's because the technology changes very quickly.

So, do we need a radical new direction then, which is what previous witnesses have stated, or do we just need to be putting right what we have in place?

Coming back to the history of investment, we haven't had any investment in endoscopy training or structures to support endoscopists for the past 10 years. So, we need to put that right. There are people and structures already in place that could be plugged into a central academy type of structure. So, we have all the course materials, we have experienced faculty, but they need to be concentrated in a way that then is matched to the needs of the health boards and the workforce—just what we were talking about, about how you identify those people—and pushes them through in an optimised way. And because there's been— 

What I'm saying is, we don't have an infrastructure to do that at the moment. People come to us on an ad hoc basis and say, 'I want this training course. Can you provide it?' It's not integrated, it's not put forward in a planned way.

So, I was having another conversation with the bowel screening team, and they were seeing the potential benefits of, at the beginning of a year, identifying people who potentially we could give a type of training to that improved their baseline performance from 90 per cent to get it up to 95 per cent, to help them pass bowel screening accreditation, et cetera. So, if you're looking to fast-track those people, you want to find them early. And if I have no other message, we need to go out and be doing this now, because if we stand and do nothing, then there's no way you're going to hit your later targets.

And having it brought together in a centralised structure means we can deliver the important central elements, we can provide the incentives to the health boards that we were talking about, and it's much more accountable, because you can look at that training structure and go, 'Well, yes, that has delivered that' or 'We need to do a bit more work to deliver that', and it's much more visible.

I understand this is very high up your agenda as a consultant gastroenterologist, but what I'd like understand is how high up the agenda of HEIW is this. One of our previous witnesses pointed out that, as a fairly new organisation, you've got a list as long as that piece of string we were talking about earlier of organisations, of disciplines, of portfolio holders, if you like, who are wanting training, wanting the whole lot to be put together. So, with your HEIW hat on, where are we with how this is going to be progressing?  

I honestly don't think I can answer that question. I'm sure that's very frustrating to you, but I'm not part of the HEIW team, as I said at the start. So, I think that is a fair question to put to their leadership team.

Sorry, I read you down here as an evidence session with HEIW, so that's why I wanted to challenge you. My apologies.

No, that's fine. I think that's a very valid question.

Grêt, diolch yn fawr. Rydym ni allan o amser. Diolch yn fawr am eich presenoldeb. Diolch yn fawr hefyd am y papur ymlaen llaw. Mi fyddwch chi'n derbyn trawsgrifiad o'r trafodaethau er mwyn i chi gael gwirio eu bod nhw'n ffeithiol gywir. Ond, diolch yn fawr iawn. Ac mi wnawn ni symud ymlaen yn syth ac yn ddirwystr i'n tystion olaf. Diolch yn fawr.

Great, thank you very much. We're out of time. Thank you for your attendance  and thank you also for the paper you submitted. You will receive a transcript of the proceedings just for you to check that they're factually correct. Thank you very much. And we'll move on straight now and smoothly to our final witnesses. Thank you very much.

13:45
7. Gwasanaethau endosgopi yng Nghymru: sesiwn dystiolaeth gyda swyddogion Llywodraeth Cymru
7. Endoscopy services in Wales: evidence session with Welsh Government officials

Prynhawn da. Dyma ni, felly, yn symud yn syth ymlaen i eitem 7, a pharhad efo'n hymchwiliad fel pwyllgor i wasanaethau endosgopi yma yng Nghymru. Dyma'r sesiwn dystiolaeth gyda swyddogion Llywodraeth Cymru, ac i'r perwyl yna rydw i'n falch iawn o groesawu i'r bwrdd Andrew Goodall, cyfarwyddwr cyffredinol iechyd a gwasanaethau cymdeithasol, a phrif weithredwr y gwasanaeth iechyd yng Nghymru, Llywodraeth Cymru; Simon Dean, dirprwy brif weithredwr y gwasanaeth iechyd yng Nghymru, Llywodraeth Cymru; a hefyd Dr Chris Jones, dirprwy brif swyddog meddygol y gwasanaeth iechyd gwladol, Llywodraeth Cymru. Croeso i'r tri ohonoch chi. Rydym ni wedi derbyn toreth o dystiolaeth ynglŷn â'r pwnc yma, felly fe awn ni'n syth i mewn i gwestiynau. Julie Morgan.

Good afternoon. Here we are, then, and we move straight now to item 7 on the agenda and a continuation of our inquiry into endoscopy services in Wales. This is the evidence session with Welsh Government officials, and I'm very happy to welcome to the table Andrew Goodall, the director general for health and social services and the chief executive of the NHS Wales; Simon Dean, who is the NHS deputy chief executive at the Welsh Government; and also Dr Chris Jones, NHS deputy chief medical officer for the Welsh Government. Welcome to all three of you. We've received a substantial amount of information, so we'll go straight into questions with Julie Morgan.

Diolch and good afternoon. I wanted to ask you about the FIT sensitivity threshold, which is, in Wales, being introduced from January 2019, and that's 150, compared to England, which is going to be 120, and Scotland, 80. So, why is it at that level in Wales, and should the Welsh Government be more ambitious?

If I could make a general comment, and then I'll pass it over to Chris to perhaps allow us to understand the policy that we've taken on this in the first place.

We've had to take a realistic view in terms of our assessment of the available capacity within our system and the evidence that the screening programme will need to move going forward. We obviously draw on evidence around us, which is around the UK screening committee. We obviously have the ability to work with those organisations of charitable status who will have a particular interest in this area, and we obviously take advice from the Welsh screening committee as well.

It's important to acknowledge that whilst we are going for the roll-out from January on the initial level that we have allocated, that is with the intention to make sure that that is complete by July, so we will have moved very speedily through into that initial process of rolling out the FIT test. Obviously, one of our reasons for moving to this is to actually try to improve our overall uptake for the scheme, because we're aware that whatever we are technically doing to deal with the capacity within the system, there is something, I think, about both awareness for population and community, but also to make sure that the ease of testing is actually dealt with as well. Certainly we've been very encouraged by looking at some of the outputs from the English pilots talking about an uptake increase of around 8 to 10 per cent. Hopefully we would see that translate into Wales, although I do think there are some specific areas that we do need to target as well. Perhaps, Chris, you could deal with some of the underlying rationale of the policy.

I suppose from a policy perspective, we take our advice from the national screening committee for the United Kingdom. That's hosted by Public Health England, but it is an established UK body of expertise, and their advice is that this should be introduced in a proportionate manner with regard to the capacity and the constraints of capacity, so that, actually, it is deliverable when you make a commitment. So, to implement it at 150 μg per gram, I think, will generate about another 300 colonoscopies but enable us to identify about 87 more cancers. If we were to reduce the threshold to 20 μg, we would identify, probably, another 170 or 180 cancers [Correction: 'around 250 cancers'], which is great, but that would be at the cost, in a sense, of an extra 8,000 endoscopies. So, there is a proportionality to this. We're being quite bold, actually, in committing to full roll-out at this threshold by next summer, but the idea then is that we will fully implement, on advice from the screening committee and also Public Health Wales, by 2013.

Twenty three—2023.

Two thousand and twenty three. I'm sorry.

I think most witnesses wanted it earlier. [Laughter.] So, basically what you're saying is that it's been determined by the current endoscopy capacity.

It's a realistic position that we believe to be deliverable, but the intention is to move progressively in terms of the age range and also in terms of the threshold as quickly as possible. We believe, actually, that this commitment will enable us to be relatively well ahead. We've seen in other parts of the UK when a lower threshold has been taken as the starting point that, actually, it's created enormous difficulties with capacity, and that hasn't necessarily been, I think, something that they felt has been helpful. I think this is a proportionate but quite progressive approach.

13:50

I think it's also important—it's the policy change and then the performance oversight of the system. So, as we go to 2023, it's to actually ensure that, underpinning that, we will have a phased implementation, moving to that reduced target and that there will be clear milestones in place for us to track. So, it's not just to get to next July at the level and then just to pause and wait until we get to 2023. We'll be having an oversight of the system in terms of what that progress would look like over that five-year period.

Yes. But just to make it clear, it is because of the capacity that you're taking this line.

Capacity, a need to maintain a level of support for the general population—just to give context, which may help, we, last year, did about 93,000 endoscopic procedures in Wales; that's in our 3 million population. We've seen an increase in our colonoscopy rates. So, there are about 21 per cent more colonoscopies that are done, and it is a realistic assessment of how we need to maintain existing services and access, where endoscopy helps a range of other areas and to particularly focus on this area as well. I'm pleased, in a sense, that the guidance that came through, which I think was pretty open and transparent, was a realistic assessment from those both in the service and from a Welsh Government perspective. But, of course, we need to maintain the ambition and make sure we're able to deliver that as well. 

If I can also add that it isn't really just about the threshold. The fact that we're implementing FIT at all is a significant commitment to improvement. The current faecal occult blood testing regime is not particularly appealing for a lot of people to engage with, and so we've struggled to engage with more than about 55 per cent of the population to take up bowel cancer screening. We do believe that, with the FIT test, it will be much more user/person-friendly, and therefore much more easy for people to engage with, and so the general uptake will increase. So, that in itself is a significant advantage.

We are worried about the reach into the population, because we know it's often the more disadvantaged populations who don't take up the screening offer.

Yes. But we do know also that, where third sector organisations make an effort to reach into those communities, actually, they can make a difference, so we want to work particularly closely with them in collaboration.

So, how does Wales compare with the other nations in terms of detecting cancer early? Does it mean, because of this threshold, that we will be behind England, for example, in the number of early cancers detected?

I think, overall, our commitment to roll out the FIT test is a more rapid roll-out programme than England. England have made various announcements over the years, but I don't think, actually, that they have quite such a clear commitment to roll out by next June for all screening offers. Our uptake is similar to the other countries—it's around 54 per cent at present, and it's proved very difficult to get it up much beyond that. Other countries are very similar.

I would balance it alongside other choices that we're making on behalf of our system. So, if you take the announcement from the Cabinet Secretary last week about the commitment to the single cancer pathway, which is a recognition about wanting to ensure that we are very focused on that early detection, making sure that we can ensure that communities go earlier if there are symptoms that are pervading so they can actually visit their GP as necessary. I think we have to take it alongside that. From the survival figures at this stage, they have been improving over recent years. We're reasonably consistent with, for example, the English position at this stage, but I do think that it's not just about the FIT test by itself. I think if you also add on the clarity about us needing to know that we have to direct and invest more resources, but I think, particularly, the single cancer pathway development last week is pretty significant—and again strongly supported by the third sector and, of course, by clinicians.

And another facet to this is that chief executives have recently signed off increased investment to enable us to undertake the genetic testing for Lynch syndrome in patients who have diagnosed bowel cancer. So, everybody now will have this genetic test to look at the failing of the DNA repair genes, and full genetic tests if they demonstrate those gene abnormalities. And that'll help us understand the risks that others in their families may face and, in a sense, how we can then surveil them, keep them under surveillance to make sure that they also are protected.

Yes. Well, just to confirm: from age 50, every two years, at a more sensitive threshold of 80, that would happen by April 2023. Is that—?

13:55

I would expect so, yes. But I think we are awaiting advice from Public Health Wales, because we do need to do the modelling to understand the capacity constraints. But the commitment is to optimise our bowel cancer screening programme, using FIT at an appropriate age range and threshold, by 2023, yes.

I'd like to understand a little bit more about why it's going to take so long. We've had evidence from clinicians today who say that if this was a priority, a sufficient priority, they could, for example, train sufficient workforce to be able to do this in 18 months, if they went flat out to do it. I think you would acknowledge—I think you have, Dr Jones, acknowledged—that there will be people who will get ill and, potentially, there will be people who will die because they won't to be called by this process. And I completely take what you say, you've got to take that broad public health approach, and there are dangers to over testing—I completely accept that. But I'd like to understand why, from you, if the clinicians are telling us, for example—and I know it's not only people that's the issue, I know there are other issues—that they could do that in 18 months, if it was enough of a priority, it's going to take us six years to get to the point when we're, potentially, testing at the same level as Scotland. I realise the service has got lots of priorities, but it would help me if you could tell me a little bit more about why that might be.

Chris, do you want to just deal with the evidence for the decision and the progress, and perhaps I could just speak on some of the workforce and the system implications of all of that?

Yes, because I'd like to come in on that as well: workforces.

It is difficult to rapidly increase endoscopy capacity; it does require a whole-organisational, a whole- system commitment because it is about the capital facilities, the infrastructure. It is about the staffing, whether that's medical staffing or nurse staffing, or, possibly, non-medical endoscopist staffing. It requires planning, it requires financing; it really is a whole-system commitment.

We are capable of demonstrating rapid change in this area; as Andrew has said to you, we are now seeing about 20 per cent more colonoscopies being undertaken than four years ago. And that's quite significant, because, actually, when you plan an endoscopy list, you have to plan twice the time for a colonoscopy as you do for an upper GI endoscopy because of its complexity. So, these things aren't simple to change quickly—

I didn't think they were, but the clinicians told us they could do the training side of it in 18 months.

I think in terms of some choices for ourselves, there is an aspect about the accreditation of our units, and, obviously, complying with the JAG status and continuing to make progress on that. As an example, irrespective of what health boards would choose to do for themselves—because, of course, they still retain the responsibility to deliver the services—we've invested about an extra £7 million-worth of capital for specific schemes, quite significant investment for some sites to put it right.

We know that we've had to address the existing waiting lists. Our eight-week target at this stage—whilst, on the one hand, we have seen an improvement in that position, a 67 per cent reduction in the patients who are waiting over eight weeks, at this stage, our intention is, as much as possible, to see if that can be cleared by the end of March next year. So, it's another staging post for us. Over the last nine years or so, we've expanded the number of gastroenterologists in Wales, for example. There's been a 50 per cent increase, but, as may have come out in the evidence this morning, of course, gastroenterologists have a range of responsibilities, including emergency takes and outpatients and other procedures that they'll undertake. So, whilst that commitment has been material, I accept that it's in the context of other capacity. One of the choices that we have to make in the NHS is, of course, it's always a balance of how we prioritise a range of different issues all at the same time. I think that's why we're being quite pragmatic in our approach to the tests at this stage, because we still have a responsibility to existing patients in here.

Things that will change, though—. I heard just some of the residual evidence of the previous session, and I would agree that there are some opportunities linked into HEIW about taking a fresh approach to this workforce-planning approach. What I can state is that the chief executive of HEIW was part of the NHS board discussion when we were agreeing our directed national approach, and the workforce is a significant area. Whilst we may need to expand more the clinical teams, as in our medical staff, I think the real scope to happen is the way in which we oversee and supervise the non-medical staff. I think there's much more we can do there.

I think our system is at fault, in a sense, that we've still only got around 20 nurse endoscopists in Wales. Only three of them are actually doing colonoscopies; I think there's more that we can do there about advanced practice. But we also need to deal with some of the supervisory and mentoring aspects. If we can align a number of those issues at the same time, our intention is to progress to 2023. Clearly, there are some opportunities to do that quicker and sooner because we've made progress; I don't think it's just a distant timetable, and I think we just need to refresh and revise that on an annual basis, but there are some quite big issues to think about on the workforce side to expand, and I would hope that, as we've done with radiology, we could make a good strategic decision, as with the imaging academy, because I do think we need to deal with this as a more exceptional area of workforce.

14:00

Yes, it was just that final point, Andrew, well, the penultimate point you made about nursing staff in particular—nurse endoscopists. Is there anything—? We heard some evidence earlier on saying that there's no reason why endoscopy nurses couldn't be trained up to deliver more of this work. Is there anything, apart from money, that would prevent health boards from just going ahead and doing that to supplement and bolster their service?

Well, if I can try and give you a balanced view of these things, over these recent months, we've stepped in to more nationally direct where we want to go with this, to call some decisions, to allocate some funding and to ensure that there is national expectation and oversight of what's happening, but none of it removes that health boards remain the responsible employing organisations that are there to deliver services on behalf of their communities.

One of the reasons for the national direction is our own concern that the pace of the decisions that the health boards have been making, whilst good in some areas, has been inconsistent, and therefore, we are trying to ensure that we bring everybody up to the same standard at this moment. But those decisions could be taken at a local level about them entering the supervisory aspects and trying to ensure that there are expressions of interest from nurses who want to progress it. But I also think that we need to make sure that it's a career choice that people want to make, and I do think there are some professional choices to make about what the advanced practice could look like in this area in particular.

And I understand the strategic direction, I was just trying to get a sense of the ability of health boards to go this way if they wanted to and if they have the capacity to do so.

Well, capacity—I have to say that in your answers to Julie about why you chose the levels that you have, you've given an unrelentingly cheery picture compared to all the other witnesses we've had so far today. I just want to make a couple of comments before I start on capacity. One is that it isn't just about cancer, is it, because when people have colonoscopies, they very often pick up other things that people have. They may be cancer-free, so you're right about 8,000 more colonoscopies will only equal to—I think you said 137 extra cases of cancer being detected, but you could pick up loads more anaemia, you might pick up loads more stuff going on in the ilium, you might pick up lots of liver things—I don't know, but there are lots of other things. And we're talking about the preventative and prudent agenda all the time and this is a preventative tool; it's about picking up stuff earlier. So, that's why I think we're quite interested in why you chose that level of 130, I think it is, rather than 120 or 80 or what have you.

The other thing that really came across when we talked to previous witnesses is that they don't have the capacity in endoscopy units at present, but Public Health Wales said very, very clearly they had the money, they'd been given the money. So, the health boards have countered with, 'Hang on a minute. We get £750 for a case, and a case might be somebody who comes in and might have to come back again and again and again for surveillance over x years, and that's all we're going to get for them.' Whereas, for example, in England, they get paid per visit £300, and, therefore, although it sounds like they have the money to set up this endoscopy and they have the capacity to do it, they don't actually have it in real terms when you amortise it out against those people who get the all-clear and you don't have to see them again and those who are going to come back. So, I just wondered, when you're looking at the capacity building, are you satisfied that the health boards are making the right strides? Do you think that there is a case for looking at how the funding of the health boards, in the provision of these services, should be structured? And, do you not just look at cancer outcomes, but do you chuck in all the other sorts of things that you might be able to pick up by doing it that I mentioned a bit earlier, when you're doing your cost-benefit analysis?

I think, first of all, just on answering the questions and trying to give the right balance, I think this is a very serious session. In our evidence paper, we clearly recognise the pressures and demands on this area. I think it was to just give a sense that what the system has tried to do is to make sure that it's able to make progress, whilst not undermining existing commitments for services, and the pressures in the system—

When I said 'cheery', I did not mean that you took it lightly, I meant more that yesterday, we had—

Yes, optimistic. Yesterday, we had a report that—one consultant who came here today described it as a new low for Wales in terms of outcomes for people with bowel cancer, so—

Indeed. And I think we have a responsibility to ensure that our approach in this area is actually driven, not necessarily by our traditional measures and where we are, but rather about how we drive a better outcome for it. Again, I go back to the single cancer pathway—that was the intention behind it. It's to make sure that we're able to address the outcomes side rather than actually just the measurement issue in itself.

But, on the funding side, I'd be interested to look at the evidence there, because, if I can just speak quite straight, health boards are responsible for the health of their population, and the funding that they receive and is allocated to them is to deliver the services on behalf of their population. So, getting into a contracting discussion, e.g. with Public Health Wales, on what that should mean for their population I think is a distraction. In part, it would probably enhance why we've determined that we'll take more of a national direction in this area, because we have to do that in a way that is clear on what we expect, but it is to make sure that the health boards do move forward. Having sat in a budget scrutiny session a couple of weeks or so ago, health boards have been given enhanced allocations into next year that allow them the headroom to make local decisions. It's perfectly possible for them to make these decisions in respect of this service. Now, again, over the last two or three years, we've tried to make sure that we've done our bit nationally. We've invested money in terms of trying to reduce waiting times, both in-year, but also on a sustainable basis. That included addressing diagnostics, and that should have given more flexibility. So, I will reflect on if you feel the evidence is that people have been wanting to making it a one-on-one discussion with Public Health Wales, because that would not be the emphasis of our system, and certainly inconsistent with how we have reflected on that in the system, and I would expect there to be progress. 

14:05

Could I just reflect on your first point about the wider benefits of colonoscopy? Clearly the bowel cancer screening programme is quite specifically about finding bowel cancer at a very early stage, early in its natural history, so that it can be prevented from progressing. There isn't evidence to use colonoscopy to screen other conditions because in the end it's quite a harmful procedure when you're looking at an asymptomatic population. So, these are people who are well in society with no symptoms, and the colonoscopy procedure requires four days of bowel preparation, sedation, many people would say it's not all that pleasant a procedure to have, and I think one just has to bear that in mind, when sort of—. I think we do know we are going to have to do a lot of colonoscopies that are negative to find these cancers, and those will be people whose lives can be affected dramatically. But this is a lot of negative—

Sorry, Chris—I do want to correct one thing; I absolutely wasn't promoting the use of endoscopy. I was looking at the cost-benefit analysis and saying that, whilst you say in order to achieve 197 or whatever it was extra cancer diagnoses we'd have done an 8,000-odd extra, I was just saying that, absolutely, that is the bowel cancer axis, if you like, but as a positive side effect of that you will pick up other things along—. So, my question was more about: do you weight it at all by saying, yes, there were those other benefits? So, that was the point. I was not actually advocating that we go out and test people left, right and centre. 

No. And you also do, when you identify something at colonoscopy, and you have to treat it and then bring people back for surveillance, in a sense medicalise someone who was previously well, and that can be quite harmful too. So, one has to see it in the round, I think, but I take your point. 

We talked about perhaps the view between Public Health Wales and health boards, so, can I just clarify that there's no—apart from the funding we all know about, there is no other funding coming downstream from a central point of view to push this forward? 

So, there are three sources of funding, if I can describe it, again in line with the budget scrutiny process. So, there is £1 million that's been made available for endoscopy, to target this arena alongside the actions. We've made £3 million available through the budget in supporting the single cancer pathway and the implementation of that, which clearly is alongside these types of developments, and there is additional allocation that is going out to the health boards in Wales in terms of choices that they can make on a local basis for priorities on behalf of their local community. 

Do you think that all three of those funds will be able to combine to sort out the over 1,000 people who've been waiting over eight weeks for an endoscopy? Where would that come from?

Simon, do you want to just—do you want to just speak about the improvement in waiting times and maybe how we continue to expect to improve that going forward?

Yes, indeed. As Dr Goodall said a few moments ago, that number of people waiting over eight weeks has reduced. There are still a number to treat and we do expect health boards to achieve those targets. Perhaps just to add a fourth source of funding, there's capital funding as well to provide for necessary facilities. Our expectation is that the NHS provides appropriate bowel screening and provides appropriate cancer endoscopy diagnostics and provides appropriate endoscopy to support planned care more generally. And it's working with health boards, as they do their planning, to achieve that position, and we'd be looking to see significant improvements through next year's integrated medium-term plans. We'd expect the waiting time target to be hit for the single cancer pathway to be prepared for full implementation and, as Chris has indicated, to prepare for the roll-out of bowel cancer screening.

14:10

Sorry, but can I just come back on one thing? With the greatest respect—you know when somebody says that they're about to be quite rude but, you know, with the greatest of respect—'appropriate'; you used the word 'appropriate' on three or four different levels there, and yet we have got the worst outcomes. So, you know, we're not appropriate, are we? 

And that's why we're taking an approach that is more national direction in support of health boards as they exercise their responsibilities to deliver services locally. And it's why the Cabinet Secretary's made announcements on the single cancer pathway, and it's why we're implementing the bowel cancer screening programme—

Okay, this is inspiring a couple of supplementaries. Neil, and then Rhianon. 

If I can return to this question of priorities, of course, you have to make lots of unpalatable choices in running the health service—needs and means, and all that—but I can't myself see why this shouldn't be an absolutely top priority. I don't know if you listened to the evidence given this morning by Mr Torkington, but he, effectively, said that if you catch this cancer at an early enough stage, then that's it solved—problem solved—it's not going to develop and probably won't recur. So, it's a life and death decision that we've got here. There are lots of other decisions in the health service that, no doubt, are very distressing, but they're not life and death conditions. So, why aren't we putting a life and death decision above many others? 

Many aspects of the health service are about balancing those sorts of choices between emergency patients coming through the front door, how we support the system. We invest close to £0.5 billion in cancer services. That shows it's a real priority. We're expanding that with the budget scrutiny process. I know Jared well; I worked with him in Cardiff in his time. He's an excellent clinician. And we do need to make sure that we're able to respond to these individual areas, and we are not just targeting cancer in overall terms—we are actually taking a whole range of actions on bowel cancer specifically, not least as we've outlined in our evidence paper. So, it is a serious priority for us. 

On that particular point, you've mentioned national direction on a number of occasions since we've started this session. There's been an awful lot of conversation about how the agencies that we have in place can better direct clinical training and nurse training. A simple point has been brought up in terms of capacity around nurse staffing, and the restructuring of that so that there's consistency across Wales. How are you nationally directing? And, obviously, we've had some excellent news around the single pathway for cancer, and a number of different announcements, but, in regard to the variation across Wales and the fact that we know that some of the buildings are not in a good condition, and the fact that the support staff in some local health boards are very, very variable compared to others, what form does the national direction take? And, if we are absolutely going to deliver what we intend to deliver in terms of the FIT test, and the wider responsibilities around CPD for the clinicians, what are we doing in terms of an endoscopy academy? 

Perhaps if I could ask Chris to lead—Simon and Chris are both chairing and leading that approach as co-chairs, deliberately, to make sure we've got the system balanced and then the clinical perspective from Chris. But, Chris, do you want to start that? 

It may help to reflect on the experiences of the endoscopy implementation group, which has existed up to now. I've chaired that group for quite a large part of its lifetime, and it has encompassed brilliant clinical leadership, and you've met a lot of the members of this group today. But I think the feeling has been that they haven't always been able to carry change through the support of their planning colleagues, finance colleagues and all the different executive strands that are needed to create this whole system change. So, my feeling is—. And there was a degree of frustration as a result of that. So, my feeling is that Simon and I, when we take forward this national programme, we're planning to start by getting everybody in the same room for a workshop to agree what needs to be done, whether it's about capital, whether it's about JAG accreditation, whether it's about workforce—

So, the national direction you're talking about is at a very preliminary stage outside of the group, in terms of gathering all the different facets together. 

We endorsed it through the NHS board back in September. We triggered it by some concerns about some of the impact of bowel screening on a local basis, which just demonstrated we need to do something different. There are a series of recommendations that have been part of the implementation group, and it was just to move ourselves away from simply expecting that health boards would pick it up on a local basis. 

14:15

No, because that's not necessarily happening, and you mentioned the word 'exceptional' earlier on today. So, in terms of this workshop, I think it will be very, very interesting for us to understand what is happening, because the call from every single witness so far has been the need for more national coherence on this, and a bigger national direction, and, in a sense, more from you guys and girls. 

Indeed. And that would have been consistent with the feedback on the parliamentary review, and also how we framed 'A Healthier Wales', about stepping into areas in a very different way, which I think this is one of those early examples of. The workshop is happening on 12 December. To reassure you, what it hasn't done is got in the way of existing commitments and actions that we have already picked up on. So, when we did sign that off at the executive board, it was with a series of clear actions. It's about enhancing those going forward, and, I think, just to continue to maintain, I still think, good relations for the sector, through to the clinicians and the health boards themselves. 

Excellent. We need some agility now, team, and the lead on agility is Dawn Bowden. 

Thank you, Chair. Diagnostic endoscopy services, we've already talked about the pressures on that, and we've heard that some health boards have been insourcing and outsourcing services, and so on. Do you know the extent of that because of the pressures on the services, and what the potential costs of all of that have been?

No. I don't know the extent in each organisation, because, obviously, these are local decisions that health boards make. But Simon and Andrew will know how much money has been given to the NHS to help them deal with waiting times, and I do know a certain amount of those moneys have been used to outsource and insource to bring endoscopy waiting times down. The endoscopy implementation group was pleased to see improvement in capacity and improvement in waiting times. But we do recognise that not all of that capacity has been delivered through sustainable means. And I think there's a lot of money being spent in this area. If we can be more strategic, with a nationally-directed approach, bringing whole organisations to the table, and demanding, in a sense, that they give this priority, a more sustainable arrangement will follow.

So, it's a better plan rather than ad hoc, as it's possibly been. 

But just a comment, not necessarily this year, but last year, on diagnostics across Wales, to improve it, we probably at least put in an additional £5 million. But that was to really target the waiting list. Of course, there are patients simply who go on a waiting list locally to be addressed. We've already spoken about the workforce difficulties there, which is why some of that outsourcing has been necessary. But it has also seen the emergence of some areas, with Cwm Taf taking more of a lead around diagnostic services, for example, which allows them to have a more sustainable service, not just for the Cwm Taf community, but, actually, more for south-east Wales as well. So, there have been some choices that have been made to do that, just on a non-recurrent basis. 

Yes. Just a quick question around the JAG, and the fact that we've only had six units across Wales that have been accredited. Any particular reasons why we haven't had more units accredited, because I think we've got about 20 across Wales, I think?

A couple of comments from me initially, but, again, Chris can outline on the clinical side. Firstly, there's a range of factors that affect the accreditation. So, as much as you might well have enhanced your facilities and developed them, there is a factor that is simply about the waiting times, which is why you've got to address it. So, it's the operational side of the service, as well as the facilities. 

Secondly, whilst areas across the UK are seeking this accreditation, it's not a mandatory issue, but, certainly, you would want to make sure that you're able to aspire to those sorts of standards and areas. Actually, the standards were also enhanced and revised back in 2016. So, whilst the system had been making progress, obviously, there was then a higher standard that was applied. But, Chris, you may be able to help with—. 

I don't have a lot to add, in a way. These are very demanding standards. They're in four domains—quality, patient experience, the workforce and training. And there are about 70 different measures. And they do describe a perfect system and a perfect service. So, for instance, within the quality domain, there are issues around case selection, as well as recording of information and clinical audit and leadership as well. So, they're very wide standards. Some of them have been difficult for physical reasons. So, the separation of patients coming into the endoscopy suite with those leaving the suite, the separation of dirty equipment from clean equipment, all requires physical changes, and, in some hospitals, the endoscopy suite is quite constrained, and, actually, it's very difficult, really, to imagine how you can meet those standards. 

A physical issue. There's just no space around the current—

And most of them accredited are not in the main urban conurbations either, so the waiting list would be key to that then, I guess, in the larger areas. 

Yes. Powys and all of the hospitals in Hywel Dda are JAG accredited. We're now seeing JAG accreditation come to hospitals in the Abertawe Bro Morgannwg area as well. But it is true that it has been difficult. We've given quite a lot of capital moneys over the last four years since this commitment was made to help organisations get to this point, but still the waiting time has often been a challenge as well. But most of the standards are met in most of our units. 

14:20

And the objective, presumably, still is to get all 20 accredited in due course. 

Yes, to continue to make progress, and we will continue to need to put in capital money. Although organisations can choose that from their local capital, I still think that it's going to be inevitable that there'll be national capital needs as well. In north Wales, we had to give nearly £3 million to Betsi Cadwaladr, for example, for a very significant change to their facilities that was rather unexpected.

Okay. Angela, do you want to come in on this one?

You've talked a lot about giving a national direction et cetera. Is this one of these 'once for Wales' decisions?

Yes, I think so. I think we've allowed it to be regionally led by the individual organisations. I think we are setting out our expectations nationally. I think I would expect and hope that we can get to an equivalent of the imaging academy. That will be a national decision that we take together, rather than just only relying on them. I think it is an example of 'once for Wales'. Obviously, you can't do 'once for Wales' on absolutely all fronts, but I think this is a significant priority—

No, no—I agree with that. But, of course, the parliamentary review talked about the centre taking 'once for Wales' decisions, and we all know how very difficult it is to herd the health boards in the same direction. So, I just wondered if something like this, where, as Neil said, we could wipe out bowel cancer, could be or would be a 'once for Wales' decision.

Indeed. I think we've already made that 'once for Wales' decision, and I think the single cancer pathway was a 'once for Wales' decision as well, about the measurement that would happen across those pathways right across Wales, and it is for consistency and outcomes, as you've outlined yourself.

Okay, the last couple of questions are going to have to come from Helen Mary Jones.

I think one of them I may be able to leave. If I can take us back to workforce, the evidence that we've received so far suggests that workforce planning up to now has been based on poor data, incomplete data, health boards looking at what they feel they can afford or what they've already got and what they can do with what they've got, rather than trying to deliver really clinical best practice. I wonder if you think that's a fair assessment and if you can tell us in what ways the NHS executive and Welsh Government can support health boards to overcome this problem with the diagnostic workforce.

I think there has been a tradition and a culture around workforce planning, which is to take the numbers that you have in a single year and then probably to roll over those similar numbers. I think we have tried to change that, certainly over the course of the last three years. We've expanded overall numbers—this is across other workforces, not just in this arena, so choices on nurses or midwives et cetera—to try and expand. The establishment of Health Education and Improvement Wales was a decision about a national organisation that would be there to provide some system leadership and support for workforce oversight. I think we've changed the planning regime in terms of our expectations at a level of granularity around workforce numbers as well, which would include expectations to be there for the diagnostic workforce as well. So, again, whilst individual organisations can discharge these things for themselves, I just think we're moving to a different territory where we have to meet that with us doing some areas ourselves nationally. I think, in the workforce space, we obviously have significant expectations for what HEIW will do.

Just to add, if I may, one of the reasons for having the national approach and the national workshop is to bring all of the information on the scale of the challenge together in one place. So, at the workshop on the twelfth, I'm expecting that that will be put alongside the demand and capacity pressures coming from bowel screening, from the cancer pathway, from supporting the endoscopy programme more generally, and allow a national discussion about what the responses are, because that can include regional service delivery models, certainly for things like workforce planning. Trying to do that by individual health board is not necessarily the answers you heard from the previous witness, whose testimony we caught. So, I'm expecting workforce planning to be a significant part of that discussion. If this is the capacity and demand that we face, how are we going to grow and shape our workforce? What's the role of individual organisations? What needs to be delivered nationally? What's the role of HEIW in supporting that? So, that'll be a key feature of the workshop on the twelfth, for precisely that reason.

It may be helpful just to outline one reason why this workforce planning may have been difficult in the past, but may be better now with our direction. If you consider the range of procedures, including bronchoscopy and cystoscopy and the GI gut-type test [Correction: 'gastro-intestinal tests'], it implies a range of different professionals who are actually contributing to this overall service. So, you've got chest physicians and you've urological surgeons and general surgeons and gastroenterologists, as you've heard. So, that means that these services have, in the past, straddled lots of clinical directorates and, in some ways, it’s been quite difficult to get an integrated approach to the whole service. But I would hope that that would come from our national direction and a more integrated approach across the whole organisation.

14:25

Chair, just to end, we’ve heard in those last two answers about hopes and expectations. What can you tell us, in the context of this new national approach, which I’m sure we’d all support, are your expectations of the health boards, and how will you hold them to account if those expectations have not been met?

I need to be clear on the waiting time itself, because, to get that initial target in place is really important; to manoeuvre into choices and decisions that will be made on the workforce side, so not to lose that within the local context; to make sure that we have the implementation of the FIT test out there, and for that to be appropriately supported with infrastructure from the LHBs; to make it a visible and explicit issue within our normal performance monitoring approaches. You know, we have our mid and end-of-year contacts in great detail with organisations, but they are supported right throughout the year, and this is a very visible area of acting differently, I think, as a system.

Okay? Rhianon, did you want your one last question on the screening, 60 per cent to 75 pert cent?

I'm happy with the screening question. As the Chair's given me an opportunity, very briefly, then—

In terms of the workshop that you're talking about, there is a difference between a whole national approach and, in national direction, a workshop that's going to co-construct something on the way forward. So, bearing in mind the strength of the evidence that we've received today on the need for further direction to absolutely underscore holistic improvements on the journey forward, what will happen after the workshop is my question.

In 'A Healthier Wales', we talked about developing a range of quality statements that set out expectations on a national level about services. This will form one of those. So, as was indicated earlier, this is about bringing the clinical community, who have been gathering around the endoscopy implementation group, together with the managerial and planning community that can help support putting clinical decisions into place in one place, agreeing a set of expectations, and then we will be expecting those to be implemented. We’ll be pursuing that through our planning and performance management processes. So, it’s getting to the position where we have an agreed approach to tackle the issues that we have in endoscopy that we will then be expecting to see the NHS put into action.

And I’d want to balance direction with co-production. I think we’ve got to a really good outcome on the single cancer pathway, because it was done with the system, with the patient voice, with the third sector, and with clinicians themselves. And even though there is direction there, we’d still want to make sure that that’s done together and collaboratively.

Excellent. That sounds like a great place to finish. Thank you very much.

Diolch yn fawr iawn i chi am eich presenoldeb. Diolch am y dystiolaeth ymlaen llaw hefyd. Mi fyddwch chi, wrth gwrs, yn derbyn trawsgrifiad o’r trafodaethau. Diolch yn fawr iawn i chi.

Thank you very much for attending, and thank you for the evidence that was submitted beforehand. You will, of course, receive a transcript of the proceedings. Thank you very much.

8. Cynnig o dan Reol Sefydlog 17.42 (vi) i benderfynu gwahardd y cyhoedd o weddill y cyfarfod hwn ac o'r cyfarfod ar 5 Rhagfyr 2018
8. Motion under Standing Order 17.42 (vi) to resolve to exclude the public from the remainder of this meeting and for the meeting on 5 December 2018

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod ac o'r cyfarfod ar 5 Rhagfyr 2018, yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting and from the meeting on 5 December 2018, in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

Reit, eitem 8 rŵan, a chynnig o dan Reol Sefydlog 17.42(vi) i benderfynu gwahardd y cyhoedd o weddill y cyfarfod hwn ac o'r cyfarfod ar 5 Rhagfyr, yr wythnos nesaf. Pawb yn gytûn?

Item 8 now, and a motion under Standing Order 17.42(vi) to resolve to exclude the public from the remainder of this meeting and from the meeting on 5 December, next week. All agreed?

Pawb yn gytûn. Awn ni i sesiwn breifat, felly.

All agreed. We'll go into private session, therefore.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 14:28.

Motion agreed.

The public part of the meeting ended at 14:28.