The Ministry of Health needs to up its game after a survey of the gastroenterologist workforce revealed a shortage of specialists to deliver the National Bowel Screening Programme, says the Gastroenterology Society president.

The New Zealand Society of Gastroenterology president, Associate Professor Michael Schultz, said the workforce picture was “alarming” with New Zealand needing 51 more specialists to provide the same level of service as Australia. Schultz also believes the Government and Ministry of Health need to dictate the number of doctors each DHB requires to actually safely deliver the rollout of the National Bowel Screening Programme.

He said the Society’s workforce survey and analysis was prompted by its fear that the Ministry of Health was basing the rollout on an overestimate of how many colonoscopies were performed each year by gastroenterology (GE) specialists. “We thought this is going to end in disaster”.

Schultz said the Ministry had now corrected its estimates ‘down a bit’ but the survey indicated there was still a lack of GE specialists – who perform the majority of public service colonoscopies – to actually deliver the numbers required by the national rollout.

He said there was also an ‘unmanageable’ increase in demand for GE specialist services in other growing areas like inflammatory bowel disease (IBD), cirrhosis and Hepatatis C which, combined with the screening rollout, was placing huge pressure on the current workforce. “Substantial numbers of patients nationwide are already enduring unacceptably long waiting times for gastroenterology follow ups, says the report, with one specialist reporting 3000 patients on their DHB’s waiting list.

The society  is calling for the Government and Ministry to direct critically under-resourced DHBs to establish new GE specialist positions and fill vacant GE specialist positions to match their population’s needs. Plus establish provincial gastroenterology training fellowships in areas like Taranaki, South Canterbury, Northland and Invercargill.  Along with increasing training opportunities for IBD and hepatology nurses and increasing the numbers of dietitians and pharmacists working in the specialty.

Don’t want screening by postcard lottery

Schultz said innovative ideas were needed to be able to deliver the national screening rollout without increasing waiting lists – in some places the major issue was lack of infrastructure and in others it was “purely workforce”.

The bowel screening rollout timeline has already been extended by a year and Schultz believed it shouldn’t been slowed down too much more as that risked screening becoming a postcard lottery. “You don’t want to come into a position that if you live in Southern DHB you get screened and in Canterbury DHB you don’t. But on the same token you need to be able to deliver it (screening)…”

A shortage of endoscopists was one of the major reasons behind initially delaying the start of the national rollout until 2017 and raising the screening threshold for being eligible for a colonoscopy. At present seven DHBs are underway with the pilot, three more are due to join in the first half of next year and the remaining ten are due to join by the end of 2021. New Zealand has one of the highest bowel cancer death rates in the country and the number of new cases per year are increasing by 15 per cent for men and 19 per cent for women.

Schultz said initial modelling for the rollout was based on the assumption that GE specialists perform an average of 660 colonoscopies per year – much higher than the survey findings which found on average 466 colonoscopies were performed (264 in public and 202 in private) by GE specialists and the much lower number of 269  (151 in public and 118 in private) by general surgeons.  (A second cohort of four nurse specialists are currently being trained to also perform endoscopies but are not expected to make a major impact on the colonoscopy workload in the short-term.)

He said the survey (based on November 2017) figures showed there were 93 GE specialists or consultants across the country – nine of whom worked exclusively in private practice – which equated to a much lower GE specialist per capita ratio (1.93/100,000) than neighbouring Australia  (3/100,000) and Scotland (2.34/100,000).

Access to specialists also differed widely across the country leading to “substantial regional, socio-economic and ethnic inequalities in access to GE treatment”. The society was calling for the Government to raise New Zealand’s gastroenterologist/population ratio to the Australian.

Schultz also pointed out that GE specialists are not just there “pushing scopes” but also carrying out a wide range of other work, in areas like IBD and hepatitis C, plus the screening rollout was also raising awareness and leading to increased referrals of people with general bowel problems “that cannot be ignored”.  “And that obviously leads to lengthening of waiting times.”

Schultz believed one of the biggest problems faced by the rollout  was that when the government directed funding to DHBs to reduce waiting lists was that lots of DHBs took the ‘quick fix’ option of outsourcing procedures to the private sector, or offering Saturday lists, rather than investing in infrastructure or employing more doctors.

Schultz was also keen for the Medical Council to follow the Australian model and gather accurate, real-time data on the number of gastroenterologists currently working, by requiring doctors to list their specific specialty when renewing their annual practising certificates each year.  At present he said it was voluntary and many ended up being listed as internal medicine specialists not gastroenterologists.

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