Introduction
This document provides guidance on establishing Gastrointestinal (GI) endoscopy networks during 2023/24. This development framework enables endoscopy teams, with support from their wider health communities, to implement local arrangements to address local need. It has been produced in collaboration with endoscopy specialists across England.
The framework sets out:
- the purpose and expected benefits of networks
- the key requirements
- roles and responsibilities in establishing and developing networks, including national support
Clinical networks are an NHS success story. They are patient-centred, population health focused and bring teams together to collaborate on an area of healthcare, where services cannot be delivered in all trusts or where efficiencies and benefits can be achieved from joint working. Examples include imaging, pathology, and trauma networks as well as cancer alliances.
The establishment of GI endoscopy networks is key to recovering and transforming endoscopy services. Their development provides a unique opportunity to: improve population outcomes from digestive diseases; improve quality and productivity; reduce inequalities; and improve the sustainability of endoscopy service provision.
Pre-covid GI endoscopy services were experiencing a year-on-year increase in demand, set against challenges including: ageing infrastructure; insufficient workforce; unclear leadership; and the requirement to improve connectivity, digitisation and data sharing. The pandemic exacerbated this.
GI endoscopy networks will help to overcome these challenges by enabling collaborative working at scale to improve services for patients and ensure continuity of care by bringing professionals and organisations together to focus on patient and population needs.
The vision for GI endoscopy services
Since the publication of Professor Sir Mike Richards’ Diagnostics; Recovery and Renewal report NHS England » Diagnostics: Recovery and Renewal – Report of the Independent Review of Diagnostic Services for NHS England, transformation has become a priority that has received significant government investment including dedicated endoscopy capital for 2022/23 to 2024/25. This provides a unique opportunity to shape GI endoscopy services for future delivery and need. GI endoscopy networks have a critical role to play in this transformation.
50 years ago endoscopy services were established with a primary purpose of diagnostic investigation – ‘let’s have a look inside’. Advancing science and technology means endoscopy is increasingly being used as a primarily therapeutic intervention and almost exclusively for endoscopic retrograde cholangiopancreatography (ERCP). This evolution requires an increasingly specialist workforce.
Currently some patients and populations may struggle to benefit from high calibre therapeutic endoscopy due to how services are delivered, constraints around workforce, estate and service configuration.
To ensure that every patient can benefit, from modern service delivery we must move from the traditional model of delivery in every hospital, to one that focuses on specialist delivery in an appropriate setting and maximise patient outcomes by bringing together colleagues through networks to serve populations, crossing traditional organisational and ICB boundaries.
This transition may require significant investment into endoscopy estate, particularly for elective endoscopy services, as recommended in the Richards report, and to deliver our ambition for earlier cancer diagnosis as set out in the NHS Long Term Plan.
At the same time collaborative GI endoscopy networks need to consider how other novel GI diagnostics can be effectively deployed to support primary care and local communities to ensure excellent patient outcomes and seamless pathways to specialist endoscopy.
Dr Robert Logan NHS England National Specialty Advisor Gastroenterology and Endoscopy.
What good looks like for GI endoscopy services
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Ambition |
Measured by: |
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Population health outcomes, associated with GI endoscopy services, will have improved with a particular focus on bowel cancer survival rates from earlier diagnosis. |
Increased percentage of upper and lower GI cancers diagnosed at stages 1 and 2 in line with the 75% early diagnosis ambition by 2028 |
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All patients will receive timely and equitable access to endoscopy procedures:
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New and safe service delivery models will be in place, which:
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Data will be harmonised through single endoscopy reporting systems across networks of care; and advances in digital transformation will support quality and sustainable endoscopy provision. |
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Facilities will have been upgraded and expanded; units will be of sufficient size and scale for modern service delivery. |
By March 2025, all regions will have a minimum of 3.5 diagnostic endoscopy rooms per 100,000 population aged 50 years and over. |
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More units will achieve and retain Royal College of Physician Joint Advisory Group (RCP JAG) accreditation, including to deliver BCSP services. |
By March 2025, at least 10% more endoscopy units will be JAG accredited from the March 2022 baseline. |
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Risk based tools will be in operation that maximise resources to patients/populations at most risk through better patient selection, targeting, and the deployment of new innovations and technologies. |
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An expanded, skilled, and sustainable workforce will be in place through the implementation of the aims and objectives of Endoscopy Training Academies. |
By March 2025 at least 10% of lists will be for training. |
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The use of resources (including productivity) will be improved as will green endoscopy service provision. |
By March 2025, at least 85% of planned service lists will be taking place; in-list productivity will be a minimum of 10 points for service lists and 8 points for training lists. |
The role of networks in realising the vision
GI endoscopy networks are a key part of achieving our vision.
Diagnostics: Recovery and Renewal defines clinical networks as vehicles for “bringing together teams, especially where services cannot be delivered in all trusts or where efficiencies and benefits can be achieved from multi-professional and cross-organisational working.”
To be successful professional groups, both clinical and non-clinical, should be engaged from all areas – particularly primary and secondary care.
Networks facilitate delivery of high quality, efficient and patient-centred care through activities including:
- Developing efficient pathways
- Developing and monitoring of agreed protocols of care
- Patient engagement and coproduction
- Workforce planning
- Equipment and facilities planning
- Facilitation of staff working across NHS boundaries
- Joint training programmes, including CPD programmes
- Centralisation of complex interventions in specific locations
- De-centralisation of care – where this improves the patient experience
- Digital connectivity
- Centralised scheduling
- Capacity and demand planning
- Avoidance of duplication of effort
Endoscopy networks are not a new concept. The Cheshire and Merseyside network provides one example of where real benefits are being realised for patients, professionals and the wider NHS.
Cheshire and Merseyside GI endoscopy network
In Cheshire and Merseyside we established our network in 2017 to tackle long-standing system- wide issues within our endoscopy services.
The network serves a population of 2.75 million people and comprises 9 trusts with endoscopy units across 12 sites. It involves all endoscopy professions and primary care engagement has been critical to our success
We started out by gaining buy-in to a shared purpose – to deliver world class endoscopy services for our population – and to be the employer of choice for endoscopy teams across the UK, providing innovative training and the flexibility for staff to work across every unit in our locality.
Initially the network initiated a small number of projects and functions, which it has built and developed. Examples of the network’s success include:
For patients:
- a cross system Trans-Nasal Endoscopy (TNE) service which has reduced waiting times for routine OGD procedures and freed up capacity for other patients who are not suitable for TNE thereby reducing their waits too
- implementation of the Thrive productivity tool to benchmark data and increase the number of patients booked per list and reducing the number of lists that start late.
- increasing care closer to home with clinicians travelling to support gaps in expertise rather than have patients travel
For professionals:
- accelerated training for bowel cancer screening clinicians, in their own trusts, increasing the number and skill base of our local screening workforce.
- unified workforce models, providing staff the opportunity to work across all trusts in our network to disseminate best practice
- facilitated support for JAG accreditation through working together on network policies and procedures, providing strong standardised governance and assurance to local teams and reducing duplication
For the wider NHS:
- developed a network procurement group that recurrently saves £200,000 on consumables and an average of £600,000 on capital spot purchases
- initiated a review of all the network’s post polypectomy surveillance patients against the latest guidance which facilitated the discharge of over 7,000 patients.
- initiated mutual aid to the trusts with the longest patient waits thereby reducing the need for expensive insourcing or waiting list initiatives
We are continually evolving our focus and we’re now in the process of developing a small number of elective endoscopy ‘mega-sites’ to enable modern service provision in keeping with the recommendations outlined in the Richards’ report.
Dr Ash Bassi Clinical Lead, Cheshire and Merseyside GI Endoscopy Network.
Delivering network benefits
The purpose of GI endoscopy networks is to realise transformational impact with a focus on:
- large scale change across complex pathways of care involving many professional groups and organisations, where planning and service delivery needs to be approached at scale
- a co-ordinated improvement approach to unwarranted variation and inequality
GI endoscopy networks are at differing stages of establishment and maturity across the country. We should now be realising the benefits that networks can bring across the whole country. During 2023/24 we want to increase the ambition with network coverage across England.
The minimum requirements that all health communities need to take include:
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GI endoscopy network establishment milestones |
Timeline |
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GI endoscopy network configurations confirmed |
Quarter 1 2023/24 |
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Network leadership and governance in place |
Quarter 2 2023/24 |
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Network transformation priorities agreed |
Quarter 3 2023/24 |
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Evaluation mechanisms confirmed |
Quarter 4 2023/24 |
From the outset and on an on-going basis time and energy needs investing in collaborative network relationships. Refer to section 9 for more information on this.
GI endoscopy network configuration
Typically, networks serve populations of 1.5 to 3 million people. To be successful the size of each network should make sense to patients, clinicians, provider and commissioning organisations. For endoscopy, strong links with training academies, research networks, other diagnostic networks and cancer alliances are important.
It is for health communities to agree their network configuration with support from NHS England regional endoscopy teams. Consideration should be given to establishing similar footprints for each of the diagnostic networks unless there are legitimate reasons not to.
Determining the configuration of GI Endoscopy Networks in the South East
The configuration of GI endoscopy networks will be straightforward in many parts of the country, aligned to ICS boundaries and coterminous with imaging and pathology networks and cancer alliances.
The context in the South East is a little more complex. We cover a population of over 9 million people who are served by 6 ICSs’, 3 cancer alliances, 4 imaging networks and 5 pathology networks.
Within this context 5 GI endoscopy networks are emerging, and it is imperative for us to work together at the earliest opportunity, confirming and developing these networks for success.
Mr Neil Cripps, Endoscopy clinical lead, NHS England South East.
A collective goal
“ERCP networks could help with focusing expertise, supporting out-of-hours provision, and improving how ERCPs are carried out. They may also be a useful way to optimise radiology resource.”
The delivery of quality and sustainable ERCP service provision is becoming an increased challenge and provides a common goal for the endoscopy community to solve together.
NHS Hospital Episode Statistics (HES) data suggests that in 2021/22, 17% of trusts reporting ERCP activity were not undertaking the recommended annual number of procedures as set out by the British Society of Gastroenterology (BSG).
Transforming the model of care by consolidating ERCP services onto sites with critical mass, optimal infrastructure, and workforce expertise, lends itself to network working. The benefits from ERCP networks should be in line to those delivered by stroke and trauma networks.
In developing this guidance, NHS England established an ERCP expert advisory group, working closely with the BSG, to produce network and service recommendations for ERCP. These network and service recommendations set out expected best practice in ERCP service provision and aim to inform local transformation endeavours in this area of care.
Developing ERCP and wider endoscopy services in North West London
The North West London ICS is an exemplar site, having co-creating a whole system plan for leading-edge endoscopy provision. This plan is resulting in ERCP services being centralised on 2 of 4 hospital sites.
To accommodate increased ERCP service provision displaced lists are delivered at another hospital in the network. NHS England has provided capital investment in support of the system plan to enable the upgrade and expansion of facilities at a centralised hospital.
This hospital is ideally placed to improve population outcomes through: timely and equitable access to endoscopy diagnostic services; delivering the expanded bowel cancer screening programme; expanding and developing new clinical areas of endoscopy service provision such as TNE; and increasing training availability for junior doctors and clinical endoscopists.
Mr Sas Banerjee, Endoscopy clinical lead, NHS England London.
Transformation priorities
Over time, to be effective all networks will need a comprehensive GI endoscopy transformation strategy covering: the service model and associated pathways of care; capacity and demand projections; estates and infrastructure including digital; workforce; and finance and investment.
As a first step networks should develop a plan outlining their transformation priorities for 2023/24 and 2024/25. Recognising the varying stages of network establishment and maturity, the focus for some might be on a small number of improvement projects for quick success and to build momentum.
The transformation of ERCP services is a priority for early national benefit and should feature in all network transformation plans. Beyond ERCP transformation it is for local communities to determine areas of transformation focus, achieving large and lasting change based on local need. Health communities may consider other clinical areas that lend themselves to network delivery such as neuro-endocrine or complex polyps.
Initial endoscopy transformation priorities in West Yorkshire and Harrogate
In West Yorkshire and Harrogate, we have achieved rapid, significant progress with our GI endoscopy network. We are developing our network-wide approach to transforming services for our local population, including through a workforce plan and service investment plans and we are ‘learning through doing’ with a number of projects.
Our transformation priorities focus on 3 areas:
- Improved quality and outcomes:
- Pathway optimisation: use of the Edinburgh dysphagia score
- Clinical guidance: implementation and monitoring including BSG iron deficiency; BSG upper and lower GI standards; BSG ERCP The Way Forward
- Clinical audit, quality and outcomes: focused on acute bleeds in smaller trusts; post colonoscopy colorectal cancer; universal JAG accreditation across local NHS estate and independent sector providers of NHS pathways
- Pre-assessment redesign: agreeing optimal processes and sharing best
- Redesign of specialist service pathways: ERCPs; Achalasia; Barretts
- Optimising capacity:
- Capacity and demand: mapping baseline demand and capacity and modelling future requirements
- Estates and equipment: Baseline mapping
- Mutual aid: establishing a system overview to support mutual aid and on-going service recovery
- Workforce:
- Workforce strategy: development of a training strategy, including for ERCP, as part of the wider West Yorkshire and Harrogate workforce strategy
- Training academy: development of the Endoscopy Training Academy spoke with South Yorkshire and Humber and North Yorkshire
Becca Spavin, Programme manager for endoscopy and community diagnostic services, West Yorkshire Association of Acute Trusts.
Network governance and leadership
There are many forms of clinical network, with the things that a network wants to achieve having a strong bearing on how it is led and constituted.
Experience from other programmes establishing clinical and diagnostic networks indicates that a clear governance structure, together with executive sponsorship and network leadership is essential for effective formation and functioning. All networks should establish and confirm their local arrangements.
The purpose and nature of GI endoscopy networks is not expected to require formal governance arrangements. It is recommended the initial focus is on instigating an overarching network governance group (for example a network board) with an underpinning structure of workstreams and associated project groups.
One workstream will need to focus on ERCP transformation. Each network will need to agree reporting, escalation and accountability arrangements based on local context. This might include alignment to a system diagnostic programme board or provider collaborative arrangement or both.
Where a patient pathway is delivered on a network-wide basis – formal governance, such as a memorandum of understanding – that defines respective roles and responsibilities is required. Already commonplace across endoscopy services these can be further developed to underpin new models of service delivery.
The central role of executive sponsorship and network leadership is fundamental to GI endoscopy networks. To manage the transformation of GI endoscopy services, networks must have dedicated clinical leadership.
Operational management support is important to work alongside the clinical lead. Leaders must be given sufficient time and support from executives to do their job effectively. Leading a GI endoscopy network is a different proposition to leading an endoscopy unit and must be an attractive proposition for potential network leaders. These network leaders will require different kinds of support.
“Endoscopy is a gateway to the diagnosis of serious GI disease, a tool for complex therapeutic intervention and a powerful cancer prevention strategy. The endoscopy transformation strategy is helping advance levelling up and access for patients to this essential service. We encourage you to create a lasting legacy through developing effective endoscopy networks that will drive ongoing improvement and set future international standards.”
Professor Andrew Chilton, NHS England Midlands Joint Endoscopy Clinical Lead.
Investing in network leadership in the South West
The South West has developed an integrated GI network which brings together the South West Endoscopy Training Academy (SWETA) and the regional endoscopy transformation team. As the clinical lead for SWETA, I have worked previously on multiple projects with the clinical lead for the Transformation Team. We share a passion for quality and training in endoscopy and the same vision and goals.
Each of our region’s ICSs has an endoscopy lead who also takes leadership responsibility for 1 or more of our network’s work-streams and for communicating goals to their ICS.
Our distributed leadership model is successful due to a shared vision, mutual respect, highly functioning, enthusiastic and committed team members working towards shared goals and a sense of “being in it together.” This has been supported by group leadership training that facilitates the sharing of ideas and promotes innovation.
Dr Paul Dunckley, Clinical Lead, South West Endoscopy Training Academy.
Collaborative network relationships
Collaborative and network working is not without challenge.
“COVID-19 drove shared purpose, innovation, and joint working but we’ve failed to embed all those changes – old and entrenched behaviours are returning.” GI endoscopy professional
“Getting engagement from everyone is challenging, the larger trusts don’t think they need to be part of a network and the more challenged trusts don’t have the headspace to engage.” Network clinical lead
Each network will need to invest in its OD strategy, with time and energy needed to nurture positive and productive collaborative relationships.
A wealth of existing research on attributes and key design features support network success. Network leaders should familiarise themselves with the evidence and seek the experience of other leads.
From the outset networks should:
- Be patient centred and population health focused
- Create shared purpose and identity
- Address the big issues and meet member needs
- Develop strong relationships and ties
- Generate helpful products and outputs
- Adopt a distributed model of leadership
- Networks should avoid:
- Over-estimating the willingness and ability of network members to collaborate
- Favouring some members over others
- Overly constraining network member independence
- Over-management that prevents the network from being dynamic and evolving
- Failing to recognise when network leadership needs to change/rotate
Networks may adopt a maturity model to underpin their development, recognising network development is rarely a linear journey. Care should be taken not to tackle and improve all dimensions of any model from the start.
Fostering network working in the North East and North Cumbria
Our North East and North Cumbria GI endoscopy network emerged as a consequence of COVID-19. It started a natural move towards a network-way of working. Once we saw the recommendations on endoscopy networks in Diagnostics: Recovery and Renewal we thought about how we could form a network: what issues would it address; what governance would we need; what would the purpose be; and who should we involve?
Generally, we recognised that the waiting list was growing and that we needed to focus on recovery; Community Diagnostic Centres were on the horizon; and we saw the potential for a networked approach to develop a system-wide response.
Our first formal meeting in November 2021 aimed to involve as many interested people as possible – including senior managers, consultants, nursing leads, commissioners and local managers from across the ICS. We built these relationships from scratch, as our ICS developed – there weren’t pre-formed structures, and we were very wary of “imposing” networks on our trusts. Communication has been the key.
Our first commitment was to develop a realistic understanding of our situation. In early 2022 we reviewed a broad range of topics: estates; JAG accreditation; staffing; capacity; pathways; triage and referral processes. This provided a clear baseline and helped us to assess our strengths, commonalities and variations. The result was a report with 41 recommendations for the network – including: all units achieve JAG accreditation; shared inventories for our kit; professionalise our workforce; consistent referral practices across our local NHS and independent sector providers; and that we have a big focus on productivity. All of our subsequent work has been based on this.
Good engagement has been the key. We can see through our sub-groups, that members were beginning to recognise the power of coming together. Everyone understands that the network is something that we are all building, it’s the sum of its parts, not an organisation in its own right but having 8 trusts working together is significant. Over time the new way of working might become more formalised – but at the moment it’s still emerging.
Strong clinical leadership has been essential, having that clarity of vision by a respected lead clinician makes it easy for everyone to get behind the network. Good, regular communication is essential with space for dialogue and mutual support. Everyone needs to feel involved, and it has helped to have an agile mindset – to keep structures, participation and workplans constantly under review.
Emma Carter, Diagnostic Programme Manager, North East and North Cumbria ICS.
Roles and responsibilities
Delivering the vision for GI endoscopy, recovering, and transforming services within a reasonable timescale requires momentum. GI endoscopy networks provide a central vehicle to realise this. To be successful everyone needs to play their part.
Clinicians and professionals have responsibility for:
- Engaging in their network with the purpose of achieving quality and sustainable service provision, across whole systems of care, and reducing inequalities in care
Integrated care systems have responsibility for:
- Agreeing the geographical footprint of their GI endoscopy network. It is expected that some network footprints will need agreement by more than one ICS.
- Establishing executive sponsorship
- Appointing, supporting, and resourcing network clinical leadership and operational management support
- Agreeing the governance structure including reporting, escalation and accountability arrangements in a local context
- Approving the network’s transformation plan, to reflect the common goal of ERCP transformation and in accordance with local priorities
- Assuring progress on the establishment, development, and operation of the network.
Integrated care boards have responsibility for:
- Commissioning best practice GI endoscopy service provision
- Brokering positive relationships and solutions across provider organisations as needed
NHS England has responsibility for:
- Supporting ICSs to identify the geographical boundaries of their networks
- Supporting ICSs to deploy national funding, for diagnostic networks, to best effect
- Providing a range of additional support to health communities to enable the effective development and operation of their GI endoscopy networks including:
- A network toolkit will contain sample documents – for example: model job descriptions for network roles; best practice examples of governance structures; template terms of reference; a digital maturity matrix. It will also include recommendations for ERCP networks and services
- Data insights – benchmarked data is already available via the Model Health System. This will be supplemented with further data intelligence and dashboards recognising the role that data plays in driving service transformation
- Capital investment to enable the transformation of GI endoscopy services across whole systems of care, through a staged approach to development. Capital and revenue funding is also available for endoscopy through the national Community Diagnostic Centre project
- Dedicated and bespoke support visits, delivered jointly from the National Gastroenterology GIRFT Lead, National Specialty Advisor for Gastroenterology and Endoscopy, and the regional endoscopy team
- Links to established networks that can provide advice and limited support for those who are starting out
- A network of networks – the national Endoscopy Transformation Project will bring network leads together nationally, at regular intervals to share best practice, peer support and provide a safe space for problem solving common challenges.
Evaluating network success
Within a non-statutory network model:
- commissioners remain accountable for the commissioning of services
- providers for the quality-of-service delivery
- the network has responsibility for delivering the transformation plan agreed by all its members
It is important to measure, share and celebrate progress achieved in developing networks and in achieving transformational impact.
As GI endoscopy networks mature, they may want to publish an annual report, sharing with patients and the public the work of their network and benefits realised in improving quality and productivity, reducing inequalities, and improving the sustainability of endoscopy service provision.
Initially assurance is required for:
- National network coverage
- The development and delivery of network transformation plans, with an initial focus on progress in transforming ERCP services
- The development and maturity of networks, including, in the first instance, confirmation of governance and leadership arrangements
Nationally, a range of metrics are in place to track improvements in realising the vision for endoscopy services. The work of GI endoscopy networks will be an essential element in moving the dial on these metrics.
Publication reference: PRN00205