Gastroenterology 1 Description of the specialty and clinical needs of patients The specialty of gastroenterology and hepatology cares for patients with both benign and malignant disorders of the gastrointestinal (GI) tract and liver. The specialty encompasses a wide range of conditions – from common disorders to highly complex problems – and specialised procedures such as endoscopic resection of cancers and transplantation. Common problems include change in bowel habit, indigestion, irritable bowel syndrome, inflammatory bowel disease, cancers of the GI tract, gastro-oesophageal reflux disease, chronic viral hepatitis and, in recent years, hepatic steatohepatitis and the rising burden of alcoholic liver disease. Gastroenterologists also see patients with a variety of general medical problems, particularly anaemia and weight loss. Much of the work, particularly to exclude organic disease in symptomatic patients and to provide rapid diagnosis and treatment for patients with suspected GI cancer, is based in outpatients. The investigations required often include endoscopy and imaging. An acute and emergency inpatient service is needed for common problems such as gastrointestinal haemorrhage, acute inflammatory bowel disease, decompensated liver disease (particularly due to alcohol), other forms of liver failure and abdominal pain. Gastroenterology departments have an essential role in the implementation of the two-week referral strategy for improving the diagnosis and treatment of GI cancers. Several departments have combined to form multidisciplinary teams (MDTs) in order to provide the critical mass of specialists needed to meet the guidelines of the Department of Health’s (DH) Clinical Outcomes Group (COG) for the provision of specialist services. 1 Tertiary referral units may receive patients with complex hepatobiliary disease and complex nutritional problems that require total parenteral nutrition, as well as those who need complex non-malignant GI surgery and complex therapeutic endoscopy. Patients who require transplantation of the liver and small intestine are referred to the small number of units that undertake organ transplantation. 2 Organisation of the service and patterns of referral Rapid changes in referral patterns due to the implementation of primary care-based commissioning have led to multiple sources of referral to gastrointestinal services, which may be shared between providers based in primary care and secondary care. Closer working between hospital specialists and GPs with a special interest should improve ’patient flows’. Most symptomatic patients are looked after by their GP, and most problems are resolved by discussion, primary care-initiated investigation, advice and medical treatment. Nonetheless, there has been a continuing steady increase in outpatient and inpatient work for gastro- enterologists, particularly in relation to alcoholic liver disease and the increasing numbers of cancers of the GI tract that occur in an aging population. 140
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Gastroenterology
1 Description of the specialty and clinical needs of patients
The specialty of gastroenterology and hepatology cares for patients with both benign and
malignant disorders of the gastrointestinal (GI) tract and liver. The specialty encompasses a
wide range of conditions – from common disorders to highly complex problems – and
specialised procedures such as endoscopic resection of cancers and transplantation.
Common problems include change in bowel habit, indigestion, irritable bowel syndrome,
inflammatory bowel disease, cancers of the GI tract, gastro-oesophageal reflux disease, chronic
viral hepatitis and, in recent years, hepatic steatohepatitis and the rising burden of alcoholic liver
disease. Gastroenterologists also see patients with a variety of general medical problems,
particularly anaemia and weight loss. Much of the work, particularly to exclude organic disease
in symptomatic patients and to provide rapid diagnosis and treatment for patients with suspected
GI cancer, is based in outpatients. The investigations required often include endoscopy and
imaging. An acute and emergency inpatient service is needed for common problems such as
A consultant-led team should look after no more than 20–25 inpatients at any time. Most
patients are admitted on emergency ‘take’ days with various general medical problems or are
gastroenterological emergencies triaged to the ward. A minority are admitted, urgently or
electively, for evaluation of GI problems. PAs need to be allocated for at least three specialist
ward rounds per week and one post-take ward round per week per consultant, bearing in mind
the RCP’s recommendations on the amount of time that should be devoted to each patient.5
Outpatient work
New patient clinic
A consultant physician in gastroenterology working alone in a new patient clinic may see
6–8 new patients in a session usually equivalent to one PA. The exact number of patients is
dependent on experience and the complexity of the problem. Each new patient should be given
20–30 minutes.
Follow-up clinics
A consultant physician working alone in a clinic for selected patients after acute medical or
gastroenterological admission may see 12–15 patients in a session usually equivalent to one PA.
A physician working alone in a specialist follow-up clinic for chronic GI and liver disease sees
12–16 patients in one session. In practice, most gastroenterologists will run clinics that involve
a mixture of new and old patients.
Support from junior medical staff
Outpatient clinics are often run with doctors in training – either foundation programme
doctors or specialist trainees. The consultant must allocate time to review the patients seen by
the trainees. The number of patients seen by junior members of staff depends on their
experience. For each junior doctor, the outpatient workload is increased by about 50% of that
undertaken by the consultant. It should be noted that this creates a potential saving only in
outpatient and endoscopy consultant sessions and not in the other components of the
consultant’s work. Moreover, this saving (which amounts to perhaps one session) is
counterbalanced by the need for the consultant to devote time to training (including training
in endoscopy). A specialist trainee should be able to see four new patients or 10 follow-up
patients or some combination of the two. Time must be allowed for training and should
amount to about half an hour during a clinic 3.5 hours in duration.
Diagnostic and therapeutic endoscopy service
The workload of a consultant physician undertaking endoscopy depends on the procedure:
� Diagnostic upper gastrointestinal endoscopy: allowing 15–20 minutes per procedure, a
maximum of 10–12 procedures should be carried out in a session equivalent to one PA.
For a teaching session, eight patients should be allocated.
� Diagnostic flexible sigmoidoscopy: a maximum of 8–10 procedures should be carried out
in a session equivalent to one PA.
� Therapeutic upper gastrointestinal endoscopy: this includes injection sclerotherapy,
banding of oesophageal varices, injection of bleeding ulcers, palliative treatment of
oesophageal cancer and placement of feeding tubes (percutaneous endoscopic
gastrostomy, PEG). Such procedures take twice or three times as long as routine upper GI
endoscopy and, allowing 30–40 minutes per procedure, 5–6 might be undertaken in a
session (4–5 for a teaching session).
� Therapeutic flexible sigmoidoscopy: this usually involves polypectomy and takes twice as
long as routine flexible sigmoidoscopy; 5–8 procedures might be undertaken in a session.
� Diagnostic and therapeutic colonoscopy: there should be a maximum of six colonoscopies
per session (three if a teaching session) allowing 30–40 minutes per procedure.
� Training endoscopy lists: it is essential that adequate time for training is allowed and that
special endoscopy training lists are scheduled into the programme. Training sessions
inevitably reduce the service throughput. Hands-on training cannot be carried out during
a busy service endoscopy list.
� Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP):
a maximum of four procedures should be carried out in one session.
� Endoscopic ultrasound: three to four procedures should be carried out in one session.
On call for gastroenterological emergencies
The BSG have published a new document on out-of-hours care3 calling for a reorganisation of
services to provide for safe care of all gastroenterological emergencies. Sessional time must be
allocated for emergency out-of-hours endoscopy work – predominantly the management of
gastrointestinal haemorrhage. In larger units with more trained endoscopists, emergency cover
that is available 24 hours a day, seven days of the week should be the aim. This can be achieved
in smaller units only by the continuing dedication of staff working long hours or by units
merging in order to provide such 24-hour care. As far as possible, the aim should be to schedule
sessions during the week and at weekends to manage patients admitted with acute GI
haemorrhage. Such rotas should include all of those with appropriate skills, particularly
members of the medical and surgical GI teams.
Nutrition service
Consultant physicians with an interest in gastroenterology are usually responsible for leading
the enteral and parenteral feeding service. This should be within the context of a MDT with
core members: dieticians, nurses, pharmacist and clinician (usually a gastroenterologist).
Supervision of home-based parenteral nutrition for patients with type 2 or 3 intestinal failure
is usually provided from specialist centres. Nutritional rounds need to be regular and would be
expected to account for two hours per week for the gastroenterologists who take responsibility
for the nutritional service. Such rounds will often include critical care and surgical wards. All
acute hospitals should have at least one nutrition nurse.6 The presence of a functioning MDT
for nutrition will dictate recognition of specialty registrar (StR) training in clinical nutrition.
This will not be the case in all acute hospitals, only 50% of which have such teams at present.
Gastroenterologists are responsible for the placement of PEG tubes and are now required to be
intimately involved in the assessment of the procedure and in obtaining consent.
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Academic medicine
The clinical contribution of academic gastroenterologists varies widely depending on their
other responsibilities. Many clinical academics provide a substantial contribution to the clinical
service, however, and often provide specialist tertiary advice.
Most academic gastroenterologists have an honorary consultant contract with their local NHS
trust, and the usual ratio of academic work to service work is about 50:50. Wide variations and
great flexibility exist in practice, but the advent of job planning has achieved greater clarity.
With such an honorary consultant contract, the academic gastroenterologist would expect to
provide proportional input into the gastroenterology service. It should be stressed that this will
be proportionate for all activities in a gastroenterologist’s job description, including support,
training, governance, teaching and administrative roles, as well as direct patient-related activities.
As local circumstances permit the negotiation of a different proportional contract, the activities
may vary from centre to centre. For example, an academic leading a very active research group
would require 70–80% of their time to be devoted to this activity. The university (or other
academic employer) would agree the proportions (including funding) with the local trust.
The academic employer is responsible for the academic time of the clinical academic. Clinical
academics inevitably develop national and international roles, and, consequently, these
activities should be allocated between academic and clinical time by local negotiation. As
academic gastroenterologists are often research leaders or leaders in the organisation and
development of clinical education, they are an important resource for their clinical colleagues.
Good relationships within a gastroenterology unit therefore are vital, so that academic input
can support the development of the clinical service and the clinicians can be involved in up-to-
date academic developments.
7 Workforce requirements for the specialty
Current workforce numbers
From 1 March 2008, there were 788 consultant gastroenterologists in England. There has been
a recent reduction in the expansion of consultant posts from around 7% per year from
2000–2005 to just fewer than 3% in the last two years. A whole-time equivalent (WTE)
consultant currently serves a population of around 70,000; however, there is considerable
regional variation. Presently, 13% of consultants are women and only 6% work part time. A
greater than 50% expansion in the number of trainees in gastroenterology has been seen over
the past five years. There are currently between 550 and 600 trainees at StR level in
gastroenterology in England.
Consultant programmed activities (PAs) required to provide a service ingastroenterology to a 250,000 population
The numbers of PAs required depends on the volume of inpatient, outpatient and endoscopic
work and can be calculated for any given workload. Although it is not yet universal practice, it
is assumed that consultant physicians with an interest in gastroenterology work together to run
a single inpatient service. Increasingly, one or more consultants will specialise in providing
hepatology services, maintaining liaison with a regional liver centre for the appropriate
management of acute liver failure, and some of the complications of cirrhosis.
Inpatient service
Three consultant PAs per week should be allocated for inpatient rounds, discharge letters and
other related administration, with an additional consultant PA per week for a post-take ward
round. Each consultant requires one PA per week to see inpatient referrals, patients and
relatives on an ad-hoc basis and to review the results of investigations. Each consultant is likely
to commit half a PA to formal MDT meetings.
Outpatient service
Outpatient services are often provided by the consultant staff and team in training. The reduction
of junior doctors’ hours and the commitment to run the emergency medical service often means
that the junior medical staff cannot attend outpatient clinics regularly. In this example, it is
assumed that the consultant physician is working alone in the outpatient department.
New outpatient referrals
A district general hospital (DGH) serving a 250,000 population should see at least 4,100 new
patients with GI conditions each year: this will be made up of about 3,600 urgent cancer
referrals, as estimated in the two-week cancer referral guidelines, and about 500 additional GI
and hepatology cases. A variable proportion of this workload – around 1,500 cases – will be
seen by gastrointestinal surgeons. The remaining 2,600 require 8–10 consultant PAs per week
for consultants working alone in the outpatient clinic. The incidence of liver disease is
increasing rapidly, particularly as a result of alcohol-associated liver damage and obesity-related
liver disease. In addition, up to 0.7% or more of the population may be carriers of hepatitis C
or B, and the workload associated with this is likely to increase.
General medical outpatient follow-up post-discharge
Up to three consultant PAs are required per week to provide this service.
Outpatient specialist follow-up clinic per week
Ten consultant PAs per week are required for this service. This assumes that the ratio of
new:return patients is about 1:3.
Diagnostic and therapeutic endoscopy service:
� Diagnostic upper GI endoscopy: the annual incidence for upper GI endoscopy in the
general population is 1.5%. Compliance with NICE guidelines is likely to reduce this to
around 1% or 2,500 procedures in a DGH serving a 250,000 population. It is assumed
that half of the procedures will be performed by GI physicians and that, with training
requirements, this will amount to three PAs per week.
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� The annual incidences of flexible sigmoidoscopy and colonoscopy are currently 0.8% and
0.6%, respectively, but with screening for colon cancer and increasing referrals through
the referral system for suspected lower GI cancer, this is presumed to increase to 1% each,
which amounts to 2,500 of each procedures annually. Half of these are likely to be
performed by GI physicians. Nine PAs per week are required for these procedures,
allowing for training requirements.
� Endoscopic ultrasound scanning (EUS) and ERCP: these are currently performed at an
annual incidence of 0.2%, with little change anticipated. Four PAs are needed for ERCP
and EUS, assuming that 80% of these are performed by GI physicians.
� Cancer screening and surveillance programmes: the need for screening high-risk groups
within the population and the move towards more screening of the general population to
identify those with cancer is now being defined more clearly.
Out-of-hours endoscopy service
This service requires up to one consultant PA per week.
Nutrition service
This service requires up to two consultant PAs per week.
Consultant programmed activities (PAs) required per week to provide aservice in gastroenterology and General Internal Medicine in a districtgeneral hospital with an average workload
Direct patient care
Where members of the junior medical staff provide support for the inpatient service and
consultants provide the outpatient and endoscopic service, about 54 PAs are required. The
number of PAs required to run the service is reduced if part of the work is undertaken by
consultant colleagues – eg those in radiology or surgery might share the endoscopic workload
over and above that assumed in the calculations above. It has been assumed that half of all
upper and lower GI endoscopic procedures will be performed by non-GI physicians – either
other consultants or nurse specialists. Regular help in outpatients from junior medical staff –
each of whom might contribute to the work done by around 50% of that recommended for a
consultant PA – will also reduce that consultant sessional requirement. The demands for
educational supervision have increased and are not likely to decrease. It should be noted that
commitments may change with the development of outreach clinics in primary care and
endoscopic services outside NHS hospitals.
Work to maintain and improve the quality of care
Additional PAs for each consultant are required for this work. This has been estimated at 2.5
PAs per consultant as per the RCP’s guidelines and includes: CPD; teaching of junior medical
staff, nursing staff and medical students; administration and management; clinical research;
and clinical governance.
On the basis of these conditions and recommendations, the number of PAs needed to provide
a clinical service in gastroenterology and general medicine for a DGH serving a 250,000
population can be calculated. Allowing 2.5 PAs for each consultant for the supporting activities
(SPAs) given above, the total is 69 PAs (this assumes six consultants all working 11.5 PAs per
week). This is about the current paid workload of consultant gastroenterologists across the UK.
Table 1 summarises the work programme of consultant gastroenterologists providing a service
for a 250,000 population, giving the recommended workload and allocation of PAs.
This number of PAs indicates that six consultants with 10–12 PAs per week would be required.
Consultant workforce requirement nationally
The calculation allows an estimate of the consultant requirement to be made. Assuming the
population of England and Wales is 52,585,000 (DH’s figures for 2004), the total need in
England and Wales is 1,262 WTE consultants in gastroenterology (with general medicine).
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Consultant physicians working with patients
Programmed Activity Workload activities (PAs)
Direct patient care
Ward rounds (except on-take and 3post-take)
Outpatient clinicsNew patients 6–8 patients per clinic 9Follow-up patients 12–15 patients per clinic 13
Diagnostic and therapeutic endoscopy Diagnostic and therapeutic upper GI endoscopy (10–12 patients per PA) 3
Diagnostic flexible sigmoidoscopy (10–12 patients per clinic) 3
Diagnostic and therapeutic colonoscopy (6 patients per clinic) 6
EUS and ERCP (5 patients per clinic) 4
Nutrition service 2
On-take and mandatory post-take rounds Rota 1:10 for this example 1
MDT meetings 3
Additional direct clinical care 6
On-call for emergency endoscopy 1(assuming some registrar input to the rota)
Total direct patient care 54
Work to maintain and improve the 15quality of care (6 consultants)
Total 69
Table 1 The work of consultant gastroenterologists generated by a 250,000 population(PAs per week)
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Assuming that the ratio between WTE and the ‘head count’ of gastroenterologists increases
from the current 1:1.2 to 1:1.3 (Workforce Review Team assumption), 1,640 posts will be
needed across England and Wales to fully meet service demand. Currently, there are 788 in
England and 45 in Wales. An approximate doubling of posts from the current position therefore
will be needed. Over the next seven years, a Certificate of Completion of Training (CCT) in
gastroenterology and general medicine is likely to be obtained by around 400 trainees over and
above those needed to replace those retiring, which will enable an expansion of 400 posts.
These calculations have taken account of an increasing demand for colonoscopy for colorectal
cancer screening. This has been estimated to generate the need for an additional 50 consultants.
The calculations do not include the extra staffing required in hospitals with a major regional
referral practice (eg regional liver units) or national centres (eg intestinal failure units).
Finally, working patterns seem to be changing gradually, so that there are more part-time
workers and increasing numbers intending to work flexibly. Although the calculations above
have taken these trends into account, they may not have done so sufficiently.
Consultant work programme/specimen job plan
Table 2 summarises an example of the work programme of consultant physicians undertaking
gastroenterology and acute general medicine, giving the recommended workload and
allocation of PAs.
Programmed Activity Workload activities (PAs)
Direct clinical care
On-take and mandatory post-take rounds (According to numbers of admissions, 1–4rota and non-consultant support.)It is recommended that all other activities are cancelled for a large proportion of the time when a consultant is on take for acute medicine, which will clearly have an impact on the routine clinical workload that can be undertaken by a consultant.
On call for emergency endoscopy 0–1
Ward rounds and other inpatient work 2(except post-take rounds – see above)
Referrals and specialist services 1(eg nutrition rounds, monitoring service)
Diagnostic and therapeutic endoscopy* Diagnostic upper GI endoscopy: 10–12† 1–2Therapeutic upper GI endoscopy: 5–6†Diagnostic flexible sigmoidoscopy: 10–12† Diagnostic and therapeutic colonoscopy: 6†Diagnostic and therapeutic ERCP: 5†
Table 2 Example work programme of consultant physician undertaking gastroenterology
continued
The figures given are the best estimate of consultant requirements from available evidence.
They will need to be reviewed to assess the impact of the European Working Time Directive
(EWTD) and the implementation and interpretation of the new consultant contract, about
which much uncertainty remains.
References
1. Department of Health. Clinical outcomes guidelines. London: DH, 2000.
2. British Society of Gastroenterology. Care of patients with gastrointestinal disorders in the United Kingdom,
a strategy for the future. London: BSG, 2006.
3. Barrison IG. Out of hours gastroenterology. A position paper. London: BSG, 2007.
4. Barrison IG, Bramble M, Wilkinson M et al. Provision of endoscopy related services in district general
hospitals. London: BSG, 2001.
5. Royal College of Physicians. Consultant physicians working with patients. Third edition. London: RCP,
2005.
6. National Institute for Health and Clinical Excellence. Nutritional support in adults, oral nutrition support,
enteral feeding and parenteral nutrition. London: NICE, 2006.
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Consultant physicians working with patients
Programmed Activity Workload activities (PAs)
Direct clinical care – continued
Outpatients (general medical or specialist) New: 6–8 patients per clinic 1–2Follow-up: 12–15 patients per clinic
Clinically related administration 1.5–2.5
Total number of direct clinical care PAs 7.5 on average
Supporting professional activities (SPAs)
Work to maintain and improve the quality Education and training, appraisal, 2.5 on average of healthcare departmental management and service
development, audit and clinical governance, CPD and revalidation, research
Other NHS responsibilities eg medical director, clinical director, Local agreement lead consultant in specialty, clinical tutor with trust
External duties eg work for deaneries, royal colleges, Local agreement specialist societies, DH or other with trustgovernment bodies
*List sizes will be reduced proportionately if training is included.†Numbers = patients per four-hour list.
Table 2 Example work programme of consultant physician undertaking gastroenterology – continued