Making changes in changing times

The plenary conference session at the British Society of Gastroenterology (BSG) annual event began with an introduction from Professor Sir Ian Gilmore, president of BSG. He first commented on the work of the Clinical Services and Standards Committee (CSSC) which undertakes work on clinical services and writes guidelines. He said: “We are very hopeful that we will soon gain approval from NICE, which means that our guidelines will be acknowledged as meeting NICE standards – a huge step forward for the BSG. The sheer volume of work currently going through the CSSC is amazing, as is the quality of its output.” Prof. Gilmore went on to discuss the sector in general, saying: “This is a time of unprecedented change. We are all being subjected to increasing regulation, and a greater requirement for evidence-based decision making at a time when the NHS is undergoing its biggest change in 60 years in an absolutely evidence-free environment. Despite all the discussions about integrated care in the community, to those on the ground, it is evident that hospitals are still very much in the front line.” However, on a positive note he went on to say: “I do now sense a realisation from the Department of Health and NHS England that, if there is to be true change in the way that care is delivered, that clinicians need to be involved and need to lead the change.” Prof. Gilmore went on to introduce the guest speaker, Sir Richard Thompson, president of the Royal College of Physicians (RCP), who took to the podium to discuss new perspectives, focusing on specialism and continuity of care. He began by saying: “There is no doubt that resources are falling in real terms, at the same time that workloads are rising, particularly in acute care. A&E admissions are rising, as is the age of those being admitted.” Despite the current thinking that advances in public health will make the population healthier and compress morbidity at the end of life, Sir Richard Thompson doubts that this will have an effect on clinicians’ workloads any time soon. He said: “I am doubtful that improved care in the community is going to work in its present format, despite many Government ministers being keen on the idea of community care reducing the tidal wave heading for hospitals. However, it is important to await the results of trials currently being undertaken trying to reduce hospital admissions. For the moment, at least, the only solution is to put more specialist registrars and consultants in most specialties onto the acute rota.” Sir Richard Thompson believes that the rapid increase in admissions is due to an increasingly elderly population, and the fact that people are being kept alive for much longer, for example with better coronary care and increasing amounts of people surviving myocardial infarctions and living on into old age. He said: “The number of elderly people with multiple co-morbidities is increasing and one-third of people over the age of 80 also have dementia, which goes against the argument that if we can get people to live healthier lives they will have compressed morbidity at the end of their lives. I think it is going to prove to be very expensive to look after these people properly in the last few years of their lives.” Sir Richard Thompson went on to talk about the Future Hospital Commission (FHC) which was set up by the RCP in 2010 bringing together a range of stakeholders to identify the optimal care pathway for adult patients with a medical illness, looking at care right across the hospital environment and the balance between specialism and generalism. “The Commission will be officially reporting in September 2013,” he said. “This will then lead to a series of further programmes and reports.” Offering an idea of the emerging themes from the FHC so far, Sir Richard Thompson said that these include the prominence of acute care. He said: “Acute care is taking over and destroying many of the smaller hospitals which are becoming financially unstable because they are not receiving sufficient money from their tertiary services to underwrite them.” Other themes emerging from the FHS include the status of general medicine to cope with the increasing quantity of patients, who are mostly elderly and need complicated care, and co-ordination with specialists who are in reach. He said: “We all dream of having stable medical teams and we need to think about how we can achieve this. I believe that ‘The European Working Time Directive’ and the ‘New Deal’ are crucial and, I am told that, at last, employers are starting to negotiate with junior BMA doctors. I believe that doctors and hospitals will need to think and work differently in the future.” Sir Richard Thompson supports the idea of the seven-day working week. He said: “It is an important element of producing a good quality of care throughout the week with a stable medical team. “There certainly is increased mortality in most hospitals for those admitted during the weekend. One possible reason for this, which is often overlooked, is that it may be related to the pattern of admissions. The number of patients admitted over a weekend is generally 20%-30% lower than for the rest of the week. It may be that the average type of patient admitted over the weekend is not the same as during the rest of the week and they may be more acutely ill – those who are not-so-ill tend to wait to see their GP on a Monday morning. I believe there may actually be a weekend shift in the severity of illness of admissions which could be a reason why, if you are admitted at the weekend, you are statistically more likely to die.” There is, however, good evidence that the presence of consultants in the hospital at the weekend is important. “A study of 106 patients undertaken by Duncan Bell, through the RCP, showed that there were fewer excess weekend deaths if consultants in the hospital worked for several days together as a block,” said Sir Richard Thompson. “There were no fixed commitments – they were just concentrating on an acute medical unit and undertook at least two wards rounds each day. The RCP therefore now advises that, for consultants working on an acute medical unit, it is important to spend at least four hours there and to undertake at least two ward rounds a day, seven days a week. There needs to be a review of patients on weekend days to make sure that patients are not deteriorating and there also needs to be adequate diagnostics and support services for physicians available throughout the weekend. “There have been suggestions that today is the time for generalists,” continued Sir Richard Thompson. “In the past, generalist physicians were the rule before everyone became a specialist. However, we must begin to question whether it is now time to turn the clock back and become more generalist because of the increasing number of patients entering the system with ever more comorbidities. “It is important that the patient knows who is looking after them during their hospital stay, even though there may be interaction with many different specialists. It is my belief that once a patient is on a ward they should stay there, with a general physician looking after them, even if they are on a specialist ward.” Sir Richard Thompson concluded his presentation by saying: “It is vital that we always bear in mind what the patient wants and needs. Most patients want continuity of care – they want to be looked after by the same person right through their care. Unless we step up to the plate and think and plan for this to happen, with the Future Hospital Commission for example, we will end up being coerced centrally to do these things.”

Polypectomy assessment

The next speaker was Kinesh Patel who presented the findings from research undertaken by Imperial College London into the impact of the introduction of formalised polypectomy assessment on training in the UK. Today, polypectomies are a commonly undertaken procedure, despite it having a significant attendant risk making training for endoscopists vital. However, data published in 2009 showed that two out of every five trainees did not receive any formal assessment of their polypectomy skills and there is still no data available to show how many polypectomies are required to acquire competence in the technique. These facts were among the drivers behind the introduction of the Directly Observed Polypectomy Skills (DOPyS) assessment tool which was introduced in October 2011. Kinesh Patel takes up the story: “We wanted to look at the impact of the change following the introduction of DOPyS on training as part of the certification of trainees. We looked at trainee portfolios on paper from October 2010 to September 2011 and compared these to the electronic portfolios submitted the following year. We were particularly interested in trainee experience of polypectomy with a focus on endoscopic mucosa resection and also trainee experience of colonoscopy overall.” Data were collected on the total lifetime number of colonoscopies performed, the number of assessments for both colonoscopy and polypectomy and whether applicants had any evidence of performing polypectomy before certification of competence in colonoscopy. There were 175 applicants for certification in the first year. The median number of procedures per candidate was 287. A total of 32% of candidates had evidence of any observed polypectomy with 7% of candidates referring to training in endoscopic mucosal resection (EMR). The median number of formative colonoscopy assessments was 3 (range 0-16). In the year since DOPyS was introduced there were 150 applications for certification. The median number of procedures per candidate was 206. All of these candidates had evidence of polypectomy assessment with a median number of DOPyS of 7 (range 3-27). 89% of applicants had evidence of assessed EMR. The median number of formative colonoscopy assessments in this cohort was 32 (range 9-199). There was a significant increase in the number of logged polypectomy assessments (p <0.001), experience of EMR (p <0.001) and formative colonoscopy assessments (p <0.001). There was no significant difference in the total number of colonoscopy procedures performed. The data suggests that structured polypectomy assessment improves trainees’ documented exposure to therapeutic endoscopy as well as providing formal evidence of skills acquisition. As polypectomy plays an increasing role globally in colorectal cancer prevention, the team concluded that DOPyS provides an effective means of assessing and certifying polypectomy in order to minimise the well-recognised risks associated with this technique. Kinesh Patel concluded: “We identified that the introduction of electronic portfolios has led to an increase in documented polypectomy experience. The DOPys has been widely used and accepted and even embraced in clinical practice by both trainers and trainees and there does seem to have been an increase in exposure and training in polypectomy. Next we will look at the actual volume of polypectomy required to attain competence – as this is not yet clear.”