Out of hours gastroenterology- a position paper
Introduction; a survey of endoscopy units by the BSG in 2003 revealed that less than
50% of hospitals have twenty four hour/seven days/week access for patients requiring
diagnostic/interventional endoscopy for GI bleeding(1). A more recent
comprehensive survey of 161 endoscopy units showed a further small decline in the
availability of out of hours cover(2). The introduction of the new consultant contract
and the increasing numbers of acute medical admissions(3) have led to consultant
gastroenterologists being expected to provide an out of hours(OOH) GI bleeding
service whilst their ward-based responsibilities inexorably rise. Financial pressures
have also led to a reduction in the numbers of units having specialist endoscopy
nurses working out of hours.
The new consultant contract is incompatible with consultants taking part in an on-call
rota for GI bleeding patients with a frequency of more than 1/8 as 86% of these
consultants are also taking part in an on call rota for acute general medicine(4).
However, the new BSG strategy document ‘Care of Patients with Gastrointestinal
Disorders’ recommends that all acute hospitals should have arrangements for OOH
endoscopy staffed by appropriately trained endoscopists(5).
In the context of major reconfigurations of service where acute hospitals will serve
either large populations(>500,000) provide full A&E facilities and level 3 critical
care, or will serve smaller populations(200 to 250,000) with elective and ‘directed’
emergencies, the BSG needs to agree a clear policy for the future management of
OOH gastroenterology emergency work. The current ‘ad-hoc’ arrangements, with off
duty consultants being ‘chased’ by hospital switchboard operators, which exist in
more than 50% of trusts, are unsustainable, bad for patients, and are also impacting
adversely on the work – life balance of consultant gastroenterologists.
Although many gastroenterologists have used critical incident forms and risk registers
to highlight these significant gaps in service provision, the financial pressures on
acute trusts have led to GI bleeding not receiving the resources necessary to provide a
safe service. This position paper makes a series of recommendations to support
efforts to improve the availability of an experienced gastroenterologist not only to
deal with patients with GI bleeding ,but also patients who may require specialist
management of an urgent problem such as toxic dilatation of the colon.
The main concept supporting the need to change policy is the forthcoming
reconfiguration of acute services, which may assist the replanning of OOH
gastroenterology work. However, the Royal College of Surgeons reconfiguration
working party has quite rightly pointed out that changes in service must work to
improve patient care ,be evidence –based and be sensitive to the special issues
affecting rural and isolated smaller hospitals(6).

THE FUTURE CONFIGURATION OF SERVICES
Many different external factors are leading to an inevitable concentration of acute
work in larger hospitals, except in areas of the country where local geography
does not allow for service rationalisation. Perhaps the most significant of these
factors is the downward pressure on junior doctor hours, coupled with the
excessive costs and inefficiencies of trying to duplicate high level acute facilities
on multiple sites. The effect of amalgamation of acute units is likely to lead to a
change in service pattern familiar to those who have worked in the NHS for more
than 25 years. Rationalisation of maternity and paediatric emergency work may
predate changes in the movement of acute medical facilities. In the next two
decades these will lead District General Hospitals splitting into two distinct
types(6):
SMALLER HOSPITALS
These hospitals will receive ‘directed’ medical admissions but will not have level
3 critical care facilities. Their main focus will be on diagnostics and are likely to
be coterminus with elective surgical units. They will have outpatients and
intermediate care beds for elderly patients. Consultant gastroenterologists
working in these hospitals are unlikely to be supported by trainees and will most
likely provide an outpatient and mainly elective endoscopy service with provision
of slots each day for patients with trivial bleeds. The assessment of the severity of
bleeding will be based on locally agreed protocols based on national
guidelines(7,Mid Yorkshire Guideline)
Consideration needs to be given to , how, independent sector treatment centres,
which may contain the elective endoscopy service for an area, will provide slots
for non elective endoscopy. This needs to be negotiated nationally and quality
assured up to national GRS standards.
After resuscitation, patients with significant GI bleeding will go to larger
hospitals, these would include all known or suspected patients with varices.
There should be daily emergency endoscopy lists, Monday to Friday, for patients
with trivial bleeds. Patients admitted to the acute medical service in these
hospitals who experience significant bleeds as inpatients will be transferred after
resuscitation to a larger unit. .There will be no overnight or weekend endoscopy
in these smaller units. The role of specialist upper GI surgeons and interventional
radiologists currently working in hospitals where patients with significant GI
bleeds may no longer be managed will require discussion and resolution via the
local clinical networks(see the toolkit)
LARGER HOSPITALS:
Gastroenterological physicians and surgeons working in these units will have a
heavy emergency and inpatient workload. It has been calculated that up to 25% of
endoscopy slots in these hospitals need to be reserved for unplanned
endoscopy(8). There will need to be at least 8 consultants (physicians and
surgeons where appropriate) populating the on call rota for emergency
gastroenterology and depending on the overall numbers of physicians, it may not
be possible for these doctors to take part additionally in a GIM on call rota.
Assuming that the on call gastroenterologist works one in eight weeks with a 6
hour commitment at weekends, with possibly an additional four to six hours
during the week, this equates to 1 to 1.5 programmed activities.
It is acknowledged that there are many units which already provide a high quality
OOH service with fewer consultants on the rota, there is no intention in
recommending any changes to these current arrangements providing that these are
sustainable in the long term, and are properly resourced.
In these larger hospitals, daily, (including weekend and bank holiday) planned day
time endoscopy lists, with fully trained staff and comprehensive facilities will
need to be available.
In addition, part of the responsibilities of the on call gastroenterologist will be to
review in patients with serious GI or liver disease, possibly combined with a triage
role from the Medical Admitting Unit. These hospitals will have the full range of
interventional radiology including mesenteric angiography and TIPS.
Introduction of these new arrangements will clarify the on call requirements for
gastroenterologists and should facilitate job planning. Local Clinical Network
Leads will need to support job planning negotiations.
Some gastroenterologists who do not wish to give up general medicine may prefer
to work in smaller hospitals, others wishing to work in the larger units will
immediately or progressively ‘divorce ‘from GIM because, a frequency of more
than 1/8 on call is probably not acceptable, and, dual cover with GIM is probably
too arduous due to the increasing number of medical admissions.
The following ‘toolkit’ is designed to help consultant gastroenterologists plan for
the implementation of an OOH service where this does not currently exist.
OUT OF HOURS EMERGENCIES IN GASTROENTEROLOGY-A
‘TOOLKIT’
The toolkit intended to provide assistance to units where there is no out of hours
(OOH) consultant cover for gastroenterological emergencies. It is not intended to
replace good practice whatever the size of the hospital or unit where this is already
achieved. Thus, there is no intent to recommend transfer from, or bypassing of, small
District General Hospitals where dedicated physicians, surgeons and nurses provide a
safe OOH service. However, even these units may eventually have to change practice
if major service reconfiguration reduces the number of hospitals able to provide level
3 care.
1) Establish the workload
a)
b)
c)
Prospective 3 month data capture—phone calls OOH, recalls to the hospital,
OOH endoscopy.
Use the National GI Bleeding Survey to gather data on serious GI bleeds
Review length of stay data on patients with GI bleeds and other GI
emergencies(this will be necessary to show that funding for the OOH service
will be money saving or cost neutral)
2) Decide how you wish to implement the new service (planned weekend
endoscopy lists/recall as necessary/endoscopy nurses on call/link with other
hospitals)
3) Establish a Local Clinical Network
a)It is recommended that that a minimum of 8 physicians/surgeons form an on-call
rota. There is no evidence base to support this statement, but this seems to
provide a reasonable rota to allow a work life balance to be maintained. Note that
an increase in rota frequency can only occur with the negotiated agreement of the
consultant concerned. Continuing on the acute medical take rota may not be
possible, but some physicians may, as at present, prefer to dovetail their
gastroenterology on call responsibilities with their GIM on call.
b)Link Clinical Networks together.
Initially local networks covering populations of 400,000 to 500,000 need to be
established.
PCT’s and SHA’s require expert advice to support their commissioning decisions.
The BSG is keen to ensure that there is a robust pyramidal structure nationally to
ensure that 20-30 gastroenterologists work together under a local Chair who
would be their representative to the PCT. Most SHA’s would have perhaps five
of these groups. The Chairs of these networks would elect a SHA lead who would
be the main source of strategic advice at this level and would be the BSG rep.
There are several current pressing issues which this new BSG –sponsored network
could influence:
a) Commissioning
b) Choose and Book
c) ISTC’s
d) Private endoscopy
e) CATS
f) Informatics
In all these areas the BSG leads should liaise with colleagues in other specialities
to provide high quality professional advice on the planning and distribution of GI
services.
4) Make a Business Case for the new service
a) know your costs:
1)/endoscopy session
2)/endoscopy nurses
on call
3)costs/bed day
4)commissioning intentions for gastroenterology
b)know your PCT/SHA outside contracts with other providers(can you repatriate
work and money?)
5)Agree Quality Parameters for the new service
Don’t establish a new ‘cheap’ second –best OOH service, which cannot provide
best quality care
Ensure that safe transfer protocols are in place(9)
a)work with: the local ambulance trust/intensivists/upper and lower GI
surgeons/radiologists
NEW LOCAL NETWORKS WILL RESULT IN PATIENTS BEING
TRANSFERRED TO A’SAFE’ ENVIRONMENT FROM HOSPITALS WHERE
THERE IS NO OOH COVER. The new rotas provided by networks of GI
specialist doctors and nurses will result in these professionals covering one
hospital OOH to which GI emergencies will be transferred.
These changes in service will need to be negotiated with Surgical and
Radiological colleagues
REFERENCES
1.Douglass A, Bramble M, Barrison I
National Survey of UK Emergency Endoscopy Units. BMJ 2005;330:1000-1001
2.Pygwali et al, British Society of Gastroenterology Survey of Emergency
Gastroenterology Workload 2005(Clinical Medicine in press)
3.Shaping the future NHS- long term planning for hositals and related services.
Consultation document on the findings of the National Beds Inquiry ;DOH 2000
4.BSG manpower report 2007(N.Thompson personal communication)
5.Care of Patients with Gastrointestinal Disorders in the United Kingdom ,A
Strategy for the Future;BSG 2006
6.Delivering High-Quality Surgical Services for the Future,Royal College of
Surgeons March 2006
7.www.GRS.uk..”top 10 downloads,no: 7.
8.Provision of endoscopy and related services in district general hospitals ,BSG
2001
9.Guidelines for the transport of the critically ill adult. Intensive Care Society
2002.