GI Physiologists undertake diagnostic investigations to confirm suspected functional disorder within the gut and to guide both the medical and surgical management of patients. This contributes significantly to the care pathway of patients who may have oesophageal motility disorders, severe gastroesophageal reflux disease, chronic constipation, and faecal incontinence.

Gemma Norris

Gemma Norris is a Clinical Scientist by registration and initially trained as a Biomedical Scientist. Following her training, Gemma wished to pursue more of a patient-facing role and so applied for the Scientist Training Programme (STP), obtaining a place within the specialism of GI Physiology.

The Scientist training programme is a 3-year training scheme, provided by the National School of Healthcare Science. The programme incorporates work-based training, supported by a university-accredited master’s degree, to promote a high level of both academic and professional competence.

Following completion of the STP in 2015, Gemma began working as a Band 7 Clinical Scientist, within a small GI Physiology unit. Through professional networking within this role, she was able to provide advice and support to St Helens and Knowsley Teaching Hospitals NHS Trust, which enabled them to establish their own in-house GI Physiology service, providing specialist diagnostic investigations including:

• Oesophageal manometry
• Ambulatory 24hr pH/impedance studies
• Anorectal manometry
• Small bowel capsule endoscopy
• Patency capsule

In 2018, Gemma was successful in obtaining her current position as a Clinical Scientist and GI Physiology Service Lead at St Helens and Knowsley Teaching Hospitals NHS Trust.

Results and Benefits

St Helens and Knowsley Teaching Hospitals NHS Trust provides high standards of care to a population of approximately 360,000 people, principally from St Helens, Knowsley, Halton, and Liverpool, but also from other neighbouring areas such as Warrington, Ormskirk, and Wigan.

Prior to the addition of the GI Physiology service at the Trust, patients requiring physiological measurement and capsule endoscopy procedures, were referred to the Royal Liverpool and Broadgreen Hospitals NHS Trust and Aintree University Hospital. This resulted in patient inconvenience and often a delay in the receipt of results and reports; risking breaches of the 18-week RTT pathway. Within the first 12 months of operation, the GI Physiology service provided diagnostic assessment and evaluation for 427 patients, with 524 clinical procedures completed.

The in-house provision of the service has enhanced the patient experience and significantly reduced the turnaround of diagnostic reports. At the same time, patients no longer need to travel afield to attend appointments and the expert advice provided by on-site GI Physiologists has been extremely useful in terms of report interpretation and patient management. In addition to this, specialised MDT meetings have since been established, providing a link between medical and surgical colleagues, to discuss difficult cases and formulate the most appropriate treatment plans for certain patient groups, based on the results of their physiological investigations.

The GI Physiology service continues to demonstrate organic growth, and the addition of a second Clinical Scientist in 2020 provided the additional capacity required to appropriately manage referral numbers and patient waiting times. This was especially useful following the effect of the global Covid19 pandemic, which has seen a further increase in the demand for GI Physiology services.

In October 2020, the Trust supported Gemma to undertake the Health Education England Clinical Endoscopy Training programme. This is a 30-week programme which trains registered health professionals to perform safe diagnostic procedures in Upper or Lower GI Endoscopy.

During the training period, trainees are required to complete a minimum of two training lists per week, which is supported by 20 hours study time per week. Academic teaching is provided through a university-accredited programme to support the skills obtained within clinical practice. During the training, each candidate must complete a reflective training portfolio, one assessed clinical case study and an e-learning package. From a practical point of view, a minimum of 200 diagnostic procedures must be completed in addition to the Joint Advisory Group (JAG) Basic Skills Course, prior to application for independent practice.

Gemma chose to complete her endoscopy training in diagnostic oesophagogastroduodenoscopy (OGD) and was supported by Dr David McClements, Endoscopy Training Lead and Clinical Lead for the GI Physiology Service at St Helens and Knowsley Teaching Hospitals NHS Trust. Dr McClements provided technical and pastoral support throughout the training programme and completed regular review meetings to ensure trainee satisfaction and appropriate progression through the course.

Following completion of the programme in May 2021, Gemma is now proficient in diagnostic OGD; a test that is used to examine the lining of the gastrointestinal tract (specifically the oesophagus, stomach, and duodenum) for abnormality.

Gemma is now supporting the elective recovery of endoscopy services by performing one diagnostic OGD list per week, alongside her routine responsibilities as a Clinical Scientist. Gemma is also able to assist with cover when this is required in times of staff absence due to annual leave and sickness etc. This has helped the Trust to increase their diagnostic capacity and workforce flexibility.

Overcoming obstacles

Referrals

The GI Physiology service soon saw a notable increase in the number of patient referrals. This included an increase in the number of patients wishing to explore surgical options for upper GI dyspeptic symptoms, due to the increased media coverage surrounding PPI-associated risk factors linked to long-term use.

It soon became difficult to manage the increased demand with, with only one GI Physiologist in post which posed a risk to the 18-week RTT pathway. Because of this a business case was submitted to recruit an additional GI Physiologist to work alongside Gemma.

The business case was successful and through the addition of a second GI physiologist, physiological investigations were maximised with a view to 7 day working. This allowed for a reduction in patient waiting times whilst more than doubling clinical activity for certain investigations.

Prescribing  

In 2020, NHS England began a consultation on the proposal for the supply and administration of medicines using patient group directions by clinical scientists across the UK. Being unable to prescribe can be perceived as a barrier to Clinical Scientists, particularly when individuals are considering completing training in endoscopy. The Trust manages this obstacle by careful list planning, ensuring that a member of staff is always available to sign the PSD when this is required. This will continue as standard practice until legislation is amended, allowing Gemma to supply and administer sedation.

Next Steps

The Trust plans to further increase their GI Physiology workforce from two clinical scientists, to four clinical scientists and two clinical support workers, to continue to meet the growing demand for physiological investigations. This will allow for the acceptance of tertiary referrals from neighbouring Trusts, and an increase in the catalogue of diagnostic tests provided. Specifically, future plans currently include the addition of the Bravo capsule, for wireless pH monitoring and endoanal ultrasound, to provide anatomical assessment, alongside the functional characteristics demonstrated during a physiological assessment.

The Trust is now supporting Gemma to complete the Higher Specialist Scientist Training programme (HSST) with the National School of Healthcare Science. This is a bespoke, five-year, workplace-based training programme, supported by a doctoral level academic award and will provide Gemma with the opportunity to become eligible to apply for a consultant clinical scientist post in the future.

Key Contact Details

For more information about the work in this case study, contact the North West Diagnostics Team via email at england.nwdiagnostics@nhs.net