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Abstract
Aim The demand for bowel cancer screening (BCS) is expected to increase significantly within the next decade. Little is known about the intentions of the workforce required to meet this demand. The Joint Advisory Group on Gastrointestinal Endoscopy (JAG), the British Society of Gastroenterology (BSG) and Association of Coloproctology of Great Britain and Ireland (ACPGBI) developed the first BCS workforce survey. The aim was to assess endoscopist career intentions to aid in future workforce planning to meet the anticipated increase in BCS colonoscopy.
Methods A survey was developed by JAG, BSG and ACPGBI and disseminated to consultant, clinical and trainee endoscopists between February and April 2020. Descriptive and comparative analyses were undertaken, supported with BCS data.
Results There were 578 respondents. Screening consultants have a median of one programmed activity (PA) per week for screening, accounting for 40% of their current endoscopy workload. 38% of current screening consultants are considering giving up colonoscopy in the next 2–5 years. Retirement (58%) and pension issues (23%) are the principle reasons for this. Consultants would increase their screening PAs by 70% if able to do so. The top three activities that endoscopists would relinquish to further support screening were outpatient clinics, acute medical/surgical on call and ward cover. An extra 155 colonoscopists would be needed to fulfil increased demand and planned retirement at current PAs.
Conclusion This survey has identified a serious potential shortfall in screening colonoscopists in the next 5–10 years due to an ageing workforce and job plan pressures of aspirant BCS colonoscopists. We have outlined potential mitigations including reviewing job plans, improving workforce resources and supporting accreditation and training.
- endoscopy
Data availability statement
Data are available upon reasonable request.
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Significance of this study
What is already known on this topic
The demand for bowel cancer screening is increasing with demand expected to exceed 100 000 colonoscopies by 2025.
What this study adds
This is the first national workforce survey targeted at the entire endoscopy workforce. There is a projected shortfall of endoscopists to meet expected screening demand in 2025. A significant proportion of the current workforce will cease colonoscopy in the next 5 years. Barriers to endoscopist recruitment include the impact of other (non-endoscopic) responsibilities, personal, service and accreditation factors. However, there is a desire to increase screening activity, which may be aided through relinquishing other activities and improving training and upskilling.
How might it impact on clinical practice in the foreseeable future
The survey has identified important issues for key stakeholders (National Health Service England, Public Health England, Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians and British Society of Gastroenterology) to address in the next 5 years with recommendations to review job plans, improve workforce resources and further support accreditation and improve training opportunities.
Introduction
Delivering better outcomes for colorectal cancer (CRC) is a major part of the National Health Service (NHS) Long Term Plan1 which can be achieved through earlier diagnosis of colonic polyps and CRC via the Bowel Cancer Screening Programme (BCSP)2 or by earlier diagnosis based on urgent symptomatic referral. Over the coming years, the demand for bowel cancer screening (BCS) is expected to significantly increase, largely driven by the change from guaiac faecal occult blood test to faecal immunochemical test (FIT) and the proposed age reduction for screening reducing from 60 to 50 years of age.3 The most recent Joint Advisory Group on Gastrointestinal Endoscopy (JAG) census of endoscopy services demonstrated a 30% increase in BCS colonoscopy activity between 2017 and 2019.4
Workforce and available endoscopy capacity are two key factors that limit any increase in screening activity. Currently, little is known of how workforce issues might constrain the ambition to expand the BCS programme. This notion prompted development and dissemination of the BCS workforce survey in order to:
Understand the current contribution and future intentions of the current endoscopy screening workforce.
Determine the desire from the current endoscopy workforce to upskill and contribute to the BCS programme.
Identify characteristics and intentions of the potential future workforce trainees and non-medical endoscopists.
Knowledge of these factors will aid in planning workforce provision and future endoscopy capacity for screening and symptomatic services. The BCS workforce survey was conducted in early 2020 under the remit of the JAG, the British Society of Gastroenterology (BSG) and Association of Coloproctology of Great Britain and Ireland (ACPGBI). This is the first screening workforce survey to be conducted since the inception of the BCSP in 1998.
Methods
Study design
Question items were developed by consensus between key stakeholders in NHS England, JAG, BSG and ACPGBI. Pilot testing was undertaken by members of the BSG Endoscopy Committee and JAG governance groups. A final version of the survey was agreed between members and disseminated via the SurveyMonkey platform. Data from collated responses were supplemented by data from the BCSP database and JAG accreditation system.
Data collection
The survey was sent to all consultant and senior trainee members of the BSG and ACPGBI, all BCSP colonoscopists and all nurse/clinical endoscopists using contact databases of each stakeholder organisation. The survey was sent out between February and April 2020. Survey engagement was reinforced by two rounds of dissemination. The BCSP database was accessed as part of the data collection strategy.
Statistical analysis
Descriptive statistics were performed with categorical data reported as proportions (percentages) and numerical data as mean and SD or median and IQR where relevant. Comparative analysis between linked continuous data was performed using the Wilcoxon signed-rank test and independent data by the Kruskal-Wallis test. Categorical data were analysed through cross-tabulation statistics using χ2 or Fisher’s exact (FE) test, where appropriate. Statistical significance is indicated by p<0.05 unless otherwise stated. All statistical calculations were performed using IBM SPSS V.25. Thematic analysis of free text comments was supported by QSR International NVivo V.12 (Melbourne, Victoria, Australia).
Results
Demographics
There were 578 respondents to the survey, predominantly from members of the BSG and ACPGBI (see table 1). Responses by age range (in order of decreasing frequency) were 45–54 (37.4%), 35–44 (28.7%), 55–64 (24.4%), 25–34 (7.5%) and 65–74 (2%). Responses across UK regions were consistent (each region contributing 5% of responses) but fewer responses were noted in Wales (1%) and Northern Ireland (2%).
Role of survey respondents by total number and percentage of total (where subgroups defined, percentages are represented of total of that subgroup)
Using current BCS data, the response rate from consultant screening colonoscopists was 38% (128/337). Data were unavailable to calculate the response rate for other screening colonoscopists.
Current screening provision
Consultant screening sessions
Current screening consultants were asked how many sessions or programmed activities (PAs) they have for screening in their current job plan. The median number of current screening colonoscopy PAs per consultant is 1 (IQR 1–1.5). On average, 40% of total endoscopy PAs are dedicated for screening colonoscopy.
Differences in screening volume
Current screening consultants were subdivided into those who have less than two, or two or more screening PAs per week. Overall, only 20% (26/128) of the screening consultants surveyed perform two or more screening colonoscopy sessions per week. There was no significant difference in age (p=0.70, FE test), specialty (p=0.24, FE test) or general endoscopy PAs (p=0.42, FE test) between these groups.
Future screening provision
Screening consultant workforce
In total, screeners would consider taking on a 70% increase in screening sessions (extra 0.7 PAs per week) if the opportunity arose within their current job plan. Taking into account current screening PAs, the median number of desired screening PAs per consultant would be 2 (IQR 1.5–2.5). This represents a significant increase from current to desired screening PAs in this group (p<0.001; figure 1).
Histogram of current versus desired screening colonoscopy sessions (PAs) per week. PAs, programmed activities.
Non-screening workforce
Out of those who do not currently undertake screening, only 34% (93/273) of consultants expressed a desire to consider upskilling to become a BCS colonoscopist. In contrast, 55% (60/110) of nurse/clinical endoscopists and 75% (50/67) of trainees stated they would consider becoming screening colonoscopists.
Barriers to screening
Screening consultant workforce
In total, 38% (49/128) of current screening consultants are considering giving up colonoscopy (including screening) in the next 2–5 years. Reasons for this were mainly due to imminent retirement (59%) or pension issues (22%). When comparing the age range of the current screening cohort to the non-screening cohort (consultants only), there is a significant difference (p<0.001), with a trend for screening consultants to be older (see figure 2). Where other reasons were specified, current screeners cited burn-out, tiredness, pressure of work, not enough time to teach, administration and poor information technology systems for giving up colonoscopy.
Age range across consultant respondents, split by role.
Non-screening workforce
Overall, 66% (180/273) of non-screening consultants, 46% (50/110) of nurse/clinical endoscopists and 25% (17/67) of trainees stated they did not want to pursue screening. Reasons for this were mainly due to insufficient time in current job plan (34%) or that specialty interests lay elsewhere (27%), with similar responses across participant groups.
Participant views: barriers
Free text responses by survey participants were analysed and themes that represented barriers to screening were identified. Three main themes were identified: personal factors, training and accreditation issues and service issues (figure 3).
Thematic analysis of survey comments by respondents—perceived barriers facing the screening programme.
Sustainability
Increasing contribution to screening
Those participants who are current or aspirational screeners were asked which activities they would ideally relinquish in order to increase contribution to the screening programme, within the context and constraints of their current job plan. Across the consultant and trainee group, the top three activities were outpatient clinics (20%), acute general internal medicine (GIM)/surgical on call (18%) and GIM ward cover (15%; figure 4A). In the nurse/clinical endoscopist group, departmental administration (27%), outpatient work (21%) and management tasks (19%) were the top three activities that would be relinquished to support screening activity (figure 4B).
Stacked bar chart of top three activities participants would relinquish to increase screening contribution, by priority (in order of decreasing frequency). (A) Consultants and trainees. (B) Nurse/clinical endoscopists. GIM, general internal medicine.
Participant views: actions
Suggested actions to support future screening provision were made by survey respondents (figure 5). Three major themes were identified: increasing workforce numbers, streamlining the application and accreditation process and improving resources.
Thematic analysis of survey comments by respondents—suggested actions for future of screening programme. BCSP, Bowel Cancer Screening Programme.
Projections
By 2025, there is expected to be a demand for 100 000 screening colonoscopies.5 Workforce projections can be made based on the BCS survey and accreditation data (see online supplemental file 1 for calculations). Based on the current workforce numbers, rates of retirement and current recruitment there will be an estimated 342 screening colonoscopists in 2025 (figure 6A). Taking into account current average PAs for screening and estimated workforce, there will be a deficit of 31 053 screening procedures in 2025 (figure 6B). Based on the average current PAs for screening, 496 screening colonoscopists would be needed to fulfil the screening demand in 2025. If screening colonoscopists had an average of two screening PAs, a total of 298 colonoscopists would be needed to meet the screening demand in 2025.
Supplemental material
Projections for 2025 based on survey and bowel cancer screening data. (A) Estimated number of screening colonoscopists in 2025 compared with 2020. (B) Estimated number of screening procedures in 2025 based on current and aspirational programmed activities (PAs) in estimated workforce pool.
Discussion
The BCS workforce survey is the first comprehensive attempt to survey the entire endoscopy workforce and has identified major workforce risks to the delivery of the ambition of early cancer diagnosis.1
An ageing workforce
In the absence of any previous survey data, we have found that the current BCS endoscopy workforce is older, which probably reflects the enthusiasm to become a BCS colonoscopist following the inception of the BCSP. Therefore, not surprisingly, a significant proportion (38%) of the current screening workforce are considering relinquishing screening in the next 2–5 years mainly due to retirement and pension issues. This may also have been exacerbated by the onset of COVID-19 towards the end of the survey period. It is expected that 43% of current consultant gastroenterologists will reach retirement age in the next decade.6 There is an ongoing expansion of the gastroenterology workforce at present, but a significant proportion of consultant posts remain unfilled. Additionally, current BCS colonoscopy accreditation criteria may delay the potential recruitment of new consultants, half of whom at completion of training and do not have full colonoscopy certification with JAG.7 The BCS accreditation process is currently under review, exploring how best to develop screening colonoscopists while maintaining the high-quality outcomes associated with the BCSP.
Encouragingly, 34% of current non-screening consultants, 55% of nurse/clinical endoscopists and 75% of trainee respondents stated they would like to become screening colonoscopists. Respondents also suggested ways to increase workforce numbers including using screeners independent of their current trust or workplace. Other options include engagement of the ‘retired and returned’ population and incentivising screening as an activity.3 6 The pilot Health Education England (HEE) ‘Progression to Colonoscopy’ training programme may also contribute to an increasing nurse/clinical endoscopist cohort of colonoscopists. The cessation of bowel scope screening, the national screening programme using flexible sigmoidoscopy in the over 55s, may also spur uptake in this group.
In those that stated they did not wish to pursue screening colonoscopy, there was an appetite to increase weekly endoscopy sessions. Within this group, 34% of respondents stated that there was not enough time in their job plans to undertake screening. This represents a potential recruitment pool to engage with in supporting future screening.
Workforce activity
Within the total endoscopy sessions that current screening consultants undertake, 40% is for screening colonoscopy. It is interesting that only 20% of current BCS consultant colonoscopists perform two or more dedicated screening lists per week, with no discernible differences in age, specialty or endoscopy commitment with those that do less. If able to undertake extra screening, current screening consultants stated they would be willing to increase screening sessions by 70% or 0.7 PA per week. For those who wish to become screeners, mean desired sessions per week ranged from 1.4 to 2.0 among consultants, nurse/clinical endoscopists and trainees.
The potential increases in screening activity would need to be balanced against other commitments. The activities that participants would choose to relinquish in order to support screening predominantly centre on outpatient work, inpatient acute/ward cover and administrative duties. However, these activities are intrinsic to most current consultant and specialist nursing roles. It is estimated that 25%–40% of the current gastroenterology consultant workforce have GIM commitments.6 The Royal College of Physicians’ Future Hospital Commission report suggests that there needs to be an increased focus on support for the GIM workforce and 7-day working.8 These factors highlight how the gastroenterology workforce contribute significantly to GIM, impacting the medical endoscopist screening workforce. Cessation of GIM may only be feasible in larger trusts where there may be scope to do so. Alongside increasing the number of colonoscopists, there also needs to be increased recruitment of specialist practitioners and endoscopy nurses to meet additional demand—a recommendation from the recent independent review of diagnostic services.9
Training and accreditation
Screening colonoscopy is often a more complex and therapeutic procedure than diagnostic or surveillance colonoscopy and a factor that can inhibit pursuit of accreditation is acquisition of skill. Respondents cited insufficient training, challenging and delayed accreditation processes and lack of self-confidence as barriers to becoming screeners. Several participants stated that further training, including upskilling, requires support from key screening stakeholders. This is mirrored as a key recommendation following NHS England’s screening review.3 For medical trainees, this may be further impaired by the ‘Shape of Training’, reducing specialist training from 5 to 4 years.10 This may mean a reduction in time for endoscopy training and will have knock-on effects for screening accreditation. Creation of endoscopy academies and increasing the provision of virtual endoscopy simulators are possible solutions to support training and upskilling of screening colonoscopists.9
The COVID-19 effect
The effect of COVID-19 on endoscopy services is unprecedented. The screening programme was effectively halted and subsequently restarted with a significant backlog of planned procedures.11 Importantly, it is likely a large proportion of the screening workforce were redeployed at the peak of the pandemic to support the surge of inpatient admissions.12 This is an important consideration for workforce planning, acknowledging that a proportion of the screening workforce are ‘shared’ across other specialities or healthcare provision.
COVID-19 has had a significant impact on endoscopic training and the issues already highlighted will be exacerbated by this.13 14 Recent guidance from JAG highlights prioritising training based on time left to certificate of completion of training and likely service contribution after certification.15 COVID-19 has also impacted the current HEE ‘Flexible sigmoidoscopy’ and ‘Progression to Colonoscopy’ training programmes which have been delayed until further notice at time of writing.
Future horizons
Acknowledging the workforce issues identified, additional longer term strategies should be considered to support the expansion of BCS as set out in the NHS Long Term Plan. First, risk stratification models may support refinement of patients selected to undergo screening. This approach considers other risk factors, not just age, in predicting personal risk of future CRC. In doing so, this could lead to an individualised risk-based approach to screening, improved decision-making around colonoscopy and more efficient utilisation of services.16 The inclusion of quantitative FIT measurements, possibly with repeat FIT testing, within such models appears to be an area of promising research.17 Alternative initial screening tests such as multitarget stool DNA testing could be considered but cost-effectiveness remains an issue.16 18 An entirely different approach would be to consider alternative colonic imaging modalities, such as CT colonography19 or colon capsule endoscopy, with studies in progress to assess the latter for screening.20 Lastly, providing a screening workforce in the longer term may require earlier endoscopy subspecialisation during training to enable earlier acquisition of appropriate skills and create a larger cohort of highly skilled endoscopists. This may be complemented by specifying a minimum number of screening endoscopy lists within the job plans of BCSP-accredited colonoscopists.
Limitations
Survey-based methodology has several limitations including the introduction of bias through non-response and a low response rate. This affects the generalisability of results. Survey uptake may have been hindered by the onset of the COVID-19 pandemic, limiting engagement and responses. Lastly, projection calculations are based on data from the representative sample and interpretations will therefore be susceptible to a degree of bias.
Recommendations
Based on our analysis, some recommendations are presented for consideration in developing and supporting the current and future screening workforce.
Review job plans
Active review of job plans will identify which activities can be relinquished in order to increase time for screening.
‘Protection’ of screening colonoscopists from other activities will enable greater retainment and productivity of the existing workforce.
Trusts should actively look into flexible work patterns to engage and retain the ‘retired and returned’ population of screeners.
There should be greater support for individuals who show an interest in screening, particularly in adapting job plans to maximise attainment of minimum competency thresholds for screening.
Improving workforce resources
Shared workforce models should be considered, with screening colonoscopists able to perform procedures at multiple sites.
Incentivising screening should be considered to increase access to the potential workforce pool.
Develop funding arrangements to encourage trusts and cancer alliances to support BCS activity and consultant expansion.
Supporting accreditation and training
Barriers to accreditation should be explored on a local basis and support for training and upskilling offered where necessary.
Development of endoscopy training academies.
Focus training opportunities on trainees geared towards screening colonoscopy.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Formal ethics approval for this study was not required.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @Doc_Wot, @SiwanTG, @GastronautIan
Contributors SR performed the primary statistical analysis with support of JM and wrote the manuscript with editorial oversight from AMV, STG, IDP, AM, MC, NSF and RL. AMV, STG, IDP, MC, AM, NSF and RL developed the BCS workforce survey questions on behalf of stakeholder bodies. RB, RL, NSF and JM supported the dissemination of the survey. All authors reviewed the final manuscript prior to submission.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
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