DHBs are already struggling to meet colonoscopy targets and workforce issues are impacting on the rollout of the National Bowel Screening Programme, says the independent review released today.
Health Minister Dr David Clark released the Independent Assurance Review report which endorsed the continued rollout of the programme and said it had ‘considerable strengths’. But the review also made an extensive list of recommendations including further work to prevent the repeat of the IT concerns that saw thousands of people not receive screening invitations and on taking urgent action to develop the colonoscopy workforce and to review priorities for who receives bowel screening.
Earlier this year the Ministry of Health announced that IT issues and a shortage of colonoscopists had led to an around 12 month delay in the roll-out timetable for the national screening programme.
Clark called for the Review in wake of IT issues that saw 15,000 eligible Waitemata DHB residents miss out on invites. The Ministry of Health is developing a new National Screening Solution IT system but meanwhile the review said the programme’s current IT system still had “limited functionality” which was impacting on the programme’s ability to handle the population register, invitation process and clinical data. It recommended the Ministry continue to “monitor and manage carefully the ongoing risk” caused by the current system’s limited functionality.
Clark welcomed the report and said it was important to note that the Ministry of Health was doing ‘”everything possible” to avoid a repeat of the IT issues that saw thousands missing out on invitations. He said the Ministry was committed to implementing the recommendations of the review which also included a call for greater focus on equity of outcomes, increased engagement with DHBs, Bowel Cancer NZ, Māori and Pacific peoples, and greater clinical oversight of the programme.
Colonoscopy workforce ‘brittle’ and a risk
The review, chaired by Professor Gregor Coster, said the colonoscopy workforce capacity remains a “significant risk and is constraining the current National Bowel Screening Programme (NBSP) roll-out”.
“Colonoscopy wait-time data highlights that DHBs are struggling to meet their wait-time targets, even before the roll-out. The panel is concerned about the capacity and fragility of the colonoscopy workforce.”
It said there was an urgent need to progress efforts to train more health professionals to carry out colonoscopies so that a ‘sufficiently skilled workforce is available and funded into the future”.
The panel noted that the decision was made in 2015 to increase the age of eligibility for the national rollout of the programme from 50 to 60 because of the lack of a sufficiently trained and skilled workforce.
It said since 2013 the two main professional bodies Royal Australasian College of Physicians and the New Zealand Society of Gastroenterology have been working with Health Workforce New Zealand (HWNZ) to increase the number of gastroenterology training positions with four extra training posts a year now available. Also the first cohort of nurse endoscopists had completed their training last year and four more were to begin training this year.
The panel said it was informed that there was a sufficient colonoscopy workforce for the workload the programme’s first few years. But it still considered the workforce was at risk as: it was not distributed where demand was greatest, was ‘brittle’ as losing just a few staff could put stress on the system, the long lag time (about four years) to train people, and the increased demand for symptomatic colonoscopy.
It called for further modelling of future colonoscopy requirements to be “undertaken with urgency” including giving “greater consideration to which professional groups are involved in any training undertaken with the purpose of increasing workforce capacity”. Also that a workforce plan was needed with dedicated funding.
Review screening priorities for colonoscopies
The Ministry of Health’s waiting time standards for urgent colonoscopy places was putting pressure on DHBs and priorities for who receives colonoscopies need to be reviewed to better align with severity of risk, says the review.
The panel was told that there is ‘wide variability’ across the country on how primary care referrals for colonoscopies for symptomatic patients are handled, found the review. Also variability in how frequently surveillance colonoscopies are offered for people at increased risk of bowel cancer.
“The panel believes that the Ministry of Health standard for urgent colonoscopy places pressure on providers, and some DHBs told the panel that they see screening colonoscopies as interfering with capacity to deliver urgent and non-urgent colonoscopy for other indications,” it noted.
“This is at odds with the likelihood of bowel cancer given specific risks: studies now show that a positive FIT (faecal immunochemical test) is a stronger predictor for the presence of colorectal cancer than any patient-reported symptoms.”
It said a related issue to rolling out the screening programme was ensuring existing colonoscopy services were efficiently managed including consistent clinical guidelines and priorities for when colonoscopy is indicated. The review noted that other countries had used such guidelines to managed demand by ‘reducing over-servicing’.
“It is necessary to conduct a review of colonoscopy prioritisation processes, for screening and other indications, and to better align colonoscopy timeliness with severity of risk,” the review panel recommended.