Item 8 on the agenda this afternoon is a debate on the Health, Social Care and Sport Committee's report, 'Endoscopy services in Wales'. And I call on the Chair of the committee to move the motion—Dai Lloyd. 

Motion NDM7132 Dai Lloyd

To propose that the National Assembly for Wales:

Notes the report of the Health, Social Care and Sport Committee on endoscopy services in Wales, which was laid in the Table Office on 8 April 2019.

Motion moved.

Thank you, Dirprwy Lywydd. I’m pleased to take part in this very important debate today on the Health, Social Care and Sport Committee’s report on endoscopy services in Wales. This is the first in a series of spotlight inquiries undertaken by the committee, and over the coming months we will bringing forward short debates on our findings in a number of areas, such as dentistry, hepatitis C and community and district nursing. The committee agreed to undertake a one-day inquiry into endoscopy services because, at that time, the majority of health boards in Wales were breaching waiting times for tests that can diagnose bowel cancer. We were also told that an alarmingly low number of eligible people take part in the bowel screening programme. Screening is the best way to diagnose bowel cancer early, but, between April 2017 and March 2018, only 55.7 per cent of people eligible to take the bowel screening test in Wales actually completed it. Uptake is higher in females compared to men. There is also a strong correlation with deprivation. Uptake in the most deprived areas is 45.6 per cent compared to uptake in the least deprived areas at 63.3 per cent.

In terms of the introduction of the FIT test, from January 2019, Wales began replacing the current screening test with a simpler and more accurate one called the faecal immunochemical test—the FIT test—which is expected to increase the uptake of screening. There are concerns, however, that endoscopy units in Welsh hospitals are already struggling to cope with demand, and so, even though the new screening test is a positive improvement, it could put more strain on an already overstretched service.

We recognise that demand has to be properly managed, but we are disappointed that the thresholds for FIT testing are lower in Wales, and we’re concerned that Wales, without a clear plan to optimise the programme, will fall further behind its counterparts in other parts of the UK. We would like to see the Welsh Government, through the national endoscopy improvement programme, set out milestones for achieving programme optimisation in terms of age and sensitivity, so that these can be measured and progress can be monitored in the hope of achieving full optimisation earlier than 2023. 

Turning to waiting times, in 2015, the Welsh Government committed additional funding to improve waiting times for diagnostic tests, including those waiting for endoscopy procedures following a positive screening result. Additional funding was also provided in 2016-17. However, despite this extra funding, waiting time statistics still give cause for concern, and there needs to be a clear commitment that health boards will deliver the maximum waiting time target for diagnostic tests, namely eight weeks, by the end of 2019.

Witnesses to our inquiry described the Welsh Government’s approach to tackling issues related to capacity as reactive and short-term. A number of health boards provided details of hospitals contracting with external private providers for insourcing services to deliver endoscopy procedures within the health board on weekends, as well as outsourcing, where patients are sent to private providers at sites outside the health board, to cope with demand. While more investment is needed to get waiting times under control, there also needs to be a more sustainable approach, as outsourcing and insourcing are expensive and do not deliver a long-term solution.

To the workforce now: changes are needed to the nature and skills of the current workforce, with a commitment not only to increase the number of gastroenterologists and other medical endoscopists, but also to develop nurse and other non-medical endoscopists. The committee was therefore disappointed to hear that some nurses are paid less than others in Wales to perform endoscopy. This needs to be addressed.

The message from witnesses was that focus and pace is needed to ensure that Wales doesn’t fall behind other nations. Bowel Cancer UK, for example, wanted to see a national action plan with key milestones, so that the Welsh Government could be held to account for delivery and implementation of the plan. Witnesses also made the point that there had been a number of reviews, and that the issues, or the problems, were clear. Actions and solutions are what is needed now.

We therefore made one overarching recommendation in our report: by October 2019, the Welsh Government should work with the national endoscopy improvement programme to create and publish a national endoscopy action plan that addresses current and future demand for services, with clear timescales and targets for improvement. I welcome the Minister’s positive response to our report, and I'm pleased to say that the Welsh Government has accepted this recommendation and has committed to publishing an action plan for endoscopy services within the six-month timeframe requested by the committee. I thank the Minister for the written statement, which provided an update on the progress of the national endoscopy programme, earlier today. I am pleased that the action plan has been drafted, and I look forward to its publication, in accordance with the committee's recommendation.

To close, as the Minister said himself, it's vital to maintain the sustainability of endoscopy services so that people can reach the examinations that have been set for them in order to have the best results possible. It's now time for progress to be made, and I'm confident that the Welsh Government will provide the strong leadership that is needed to deliver this agenda. Thank you very much.

I'd like to thank the committee very much for doing this report. Unfortunately, I personally was absent on the day that you did the one-day report, but I've read your report, I've read the Government response, and of course I'm reflecting the commentary of many of my constituents who come to see me over these kinds of services. And I noted the Government's response to the recommendations made by the committee, and, to be frank, I found some of it—only some of it—very weak, because you have accepted the recommendation made by the committee. However, you say that endoscopy services are under stress because of population changes, a lower threshold for cancer investigations, an increasing demand for surveillance, and the need to expand the bowel-screening programme. In response, I would say that, as a minimum, the service should be able to respond currently to the objectives of the bowel-screening programme. Given the take-up rate is so low—a mere 55 per cent—there should be some slack already in the system in any event. To aim for a higher take-up rate without ensuring the tools are on hand to deliver the programme is a complete paradox. And I would also point out that, despite recommendations made as far back as 2013, there's been little progress made in addressing the challenges that endoscopy services throughout Wales are facing. Therefore, the challenges, Minister, that you identify in your response to the committee are nothing new. To imply otherwise is disingenuous and, above all, it allows those who are charged with planning services a measure of wriggle room that they do not merit. I see that the endoscopy implementation group wanted a more directive approach from the Government, and it's to your credit that you have moved in that direction. But it does beg the question as to the capabilities for planning and delivery within health boards. 

Given the crisis facing endoscopy services, Minister, are you able to accelerate the delivery of a national plan? The commitment in September 2018 was there, but, a year later, the terms of reference are still being finalised. It's hardly fast paced and, in the meantime, I'm concerned that services continue to stagnate and people's lives continue to be affected. If there's any way that you can see to moving that forward and increasing that pace and accelerating that so that we can deliver good endoscopy services throughout Wales I think that will be a very positive step forward. 

The welcome introduction of the FIT test has the potential to improve the uptake of screening. It should improve detection rates for bowel cancer and pre-cancerous polyps in the bowel—however, a paradox again, because there are unacceptable waiting times in play, and there needs to be a clear commitment from health boards to address this issue, because no programme can work without having the appropriately trained personnel and infrastructure in place.

The current workforce is desperately short of gastroenterologists and other medical and non-medical endoscopists. Nurses involved in delivering endoscopy services are on disparate and lower pay rates, and we need to see that the joint advisory group on gastrointestinal endoscopy accreditation—my goodness, doesn't the NHS come up with some exceptionally long words at times, shall I just say that little bit again? We need to see that the joint advisory group on gastrointestinal endoscopy accreditation is put in place so that we know, so that we can be secure, that all health boards are delivering services in line with best clinical practice.

But, Minister, the real frustration comes in the lack of planning and appropriate commitment by some health boards. Let me give you an example: Ysbyty Glan Clwyd had a stable team of three gastroenterologists: one retired, one moved, yet there was no forward planning to cope with this change; there was no plan B. Wrexham Maelor is struggling on locums; weekend capacity is struggling. So, this is a prime example of mismanagement. There's no contingency plan, there was no forward planning, and it has devastating consequences for individuals. A terminal bowel cancer patient received their invitation to meet the consultant in the same month that another consultant in another hospital said they would not make. How awful would that be to get the letter saying, 'Come along in this month to have your diagnosis confirmed' and somebody else has already told you, 'You're probably going to be dead by that point'. That health board needs to do better. The NHS needs to do better. We all need to do better.

The discussion around the report has, understandably, focused on the importance of endoscopy services to the treatment of bowel cancer in Wales, and, in response, the Welsh Government points out that it's also important for the treatment for serious non-cancerous conditions, such as Crohn's disease and ulcerative colitis, and I know that Crohn's and Colitis UK have campaigned for better endoscopy services in Wales.

And, with this report in mind, I met with Norgine, a company in my constituency, based in Tir y Berth—a very big employer, and an anchor company for the Welsh Government, who manufacture pharmaceuticals that are both treating these conditions and also used in the prep for colonoscopies. So, they have a very strong interest in this area. And it was quite an education to have met with the staff there and to talk through some of the issues. They actually, when I went there, had a copy of the committee's report on their desk. So, it was good that the committee's investigated this and shows the value of the work you're doing. It's being heard out there and it's been heard by this company.

They asked me to raise some key issues, which I talked through with them, because I'm not an expert in this area. I didn't fully understand the issues until I had that conversation with them and I read your report, which is a very good report. The key issue for them is how the efficiency of services is tackled—so, doing better with what we already have. And indeed, the Welsh Government has noted that in their response to the report's key recommendation. Norgine were concerned that, in the report itself, that efficiency wasn't explicitly examined. They said that high-quality bowel preparation prior to colonoscopy is a key area that should be addressed as part of the endoscopy action plan and that initiatives to drive efficiency gains and overall sustainability were key in what the Welsh Government should do next. They told me that inadequate bowel preparation is the leading cause of a failed colonoscopy procedure and can lead to missed or delayed diagnosis, longer and more difficult procedures and the need then to repeat procedures. They said that their operation is continually trying to improve that process and that their product is designed to do that.

They have, therefore, three key asks both of the outcome of the report and of the Welsh Government in their response. They want three things: they want the prompt publication of the endoscopy action plan, which the report has pushed for and we're starting to see. But alongside training and hospital capacity, it's important that broader areas for improvement are given the appropriate level of scrutiny—so, looking beyond simply training and hospital capacity—and if required that the committee and/or the national endoscopy programme should engage with relevant stakeholders to explore what improvements could be realised in the area of bowel preparation. What they're saying to you, Minister, is that they've got expertise and they'd be more than willing to hold that conversation with you. They're a Welsh-based company; they've been in Tir-y-berth for 50 years and they would welcome a conversation with you, particularly with regard to that better prep process.

I notice that you've issued a written statement today encouraging that efficiency gain, but I urge you to engage with that company because I learned a lot that day and I think that kind of dialogue can only help in the future design of services.

I thank the Health, Social Care and Sport Committee for their report on endoscopy services. As I, and many others, have highlighted, pressures on diagnostic services in Wales are impeding our ability to improve cancer survival rates. Bowel cancer is the second biggest cancer killer in Wales. Around 17 people die of bowel cancer each week. We have lost two of our own to this horrible disease. 

As with every cancer, early diagnosis is key to long-term survival. When diagnosed at stage 1, 90 per cent of bowel cancer patients survive. This drops to fewer than one in 10 when diagnosed at stage 4. Bowel screening is the best way to ensure early diagnosis, yet less than 10 per cent of bowel cancers are picked up by the Wales bowel screening programme.

Earlier this month, the FIT test fully replaced the old, less accurate blood test for bowel screening for anyone aged between 60 and 74. Unfortunately, the FIT test will be conducted at a much lower sensitivity due to capacity issues in endoscopy services. We will continue to miss many cancers because we don't have the workforce. Yet again, a lack of strategic workforce planning over the past couple of decades has left our NHS unable to cope with future pressures. We have to degrade our ability to detect cancer because we don't have the workforce to conduct further tests. 

The UK national screening committee believes that everyone over the age of 50 should be screened for bowel cancer in order to combat the 16,000 annual deaths due to this terrible disease. Once again, we have not taken up this recommendation due to capacity issues. This is not due to a shortage of money; it's due to a lack of forward planning and an utter failure of successive Governments to implement strategic workforce planning.

I welcome the committee's recommendation and calls for a national endoscopy action plan. I'm pleased that the Minister has accepted the committee's recommendations and that he has made it clear that the 60 per cent uptake threshold is a minimum requirement and not a target. We have to ensure uptake closer to 100 per cent, but in order to do so, we must ensure that we have sufficient capacity now to cope with the anticipated massive increase in the over-50 age bracket.

This will require strategic planning at a Welsh and UK level. I urge the Minister and Health Education and Improvement Wales to work closely with the other home nations, as well as the UK Government, to ensure that we have enough well-trained staff across our diagnostic services. We can beat this terrible disease by ensuring that everyone at risk is screened regularly and made aware of the early signs of bowel cancer. Only then can we ensure that other families don't have to go through what Sam and Steffan's families had to. Diolch yn fawr.

Thank you. Can I now call the Minister for Health and Social Services, Vaughan Gething?

Thank you, Deputy Presiding Officer. I'd like to start by thanking the Health, Social Care and Sport Committee for bringing forward today's debate on their report following their inquiry into this important issue. I recognise this is an issue that has not had much focus and attention in terms of committee reports and scrutiny in the past, and I think it's a good thing that that has taken place now. It provides questions for the Government and it's the case that we don't always have comfortable answers, but there are honest answers in our response about the current position, and indeed about our commitment to invest the time and effort that is required to deliver the sort of service that all of us in this Chamber would want for our constituents. Because I do recognise that endoscopy services are vital if we are to be in a position to deliver timely and high-quality investigations for a range of treatment areas. It's a prerequisite for delivering the diagnostic and cancer waiting times, achieving endoscopy unit accreditation, and of course delivering better outcomes for conditions such as cancer. However, we should not underestimate the very real challenges that face our NHS. It does involve necessary improvements in data and planning, recruitment and training, revising and standardising our clinical pathways, as well as capital investment in units and new digital enablers.

So, it is a multifaceted challenge, all against a background of genuine year-on-year increases in demand, which are driven both by an ageing population and changing clinical guidance. So, it requires some immediate action, of course, but that must come together with the longer-term and sustained focus that I know the committee have recognised and urged on the Government. And we agree on that, so it is not simply a matter of turning on additional funding to reduce waiting lists. That is why we will publish an endoscopy action plan as the committee recommended by the end of this October, and I will ensure it addresses the points that the committee has raised. In the meantime we have taken a range of immediate action that is required and put in place a detailed and comprehensive national programme. I have published a written statement today, which I know the Chair referred to, to outline in more detail the approach that we are taking, the progress that has been made to date, and of course the work that is due to take place in the coming months. So, we will then need to move quickly to the medium-term objective and actions that are required to stabilise endoscopy services, and then the longer-term objectives and actions needed to achieve a genuinely sustainable service. So, the programme has been set up as a nationally directed service by the Government, rather than led by the NHS, and that is consistent, if you like, in context with the ambitions that we set out in 'A Healthier Wales'. There will be times when we'll need to take a stronger, central guiding hand.

So, the new endoscopy programme board is chaired by the deputy chief executive of the NHS and the deputy chief medical officer. The board is comprised of senior health board representatives and people who represent important allied programmes of work like cancer, pathology and bowel screening. I'm thinking about Hefin David's point about the interest that Norgine have in this area, and I think it might be appropriate to see if they would meet and have direct discussion with the endoscopy board. I'll take that up in a conversation with him about the local company. But that board will oversee four work streams, looking at demand and capacity planning, workforce education and training, clinical pathway development and facilities and infrastructure requirements. Significant support is already being provided by the NHS collaborative. That includes the national programme lead and their team, as well as clinical and managerial leads for each of the four work streams that I've outlined. This programme will be supported by the £1 million allocation that I've put in place as part of the NHS budget for 2019-20. More than half of that has already been allocated to support the programme work that I have identified.

In the coming months, all units across Wales will be receiving pre-assessment visits to determine what is required locally to achieve the accreditation standard set by the Royal College of Physicians. I won’t try and deliver the full tile as Angel Burns bravely did, but there is a real challenge about making sure that the infrastructure is in place to meet those standards. I recently met with the team in the Royal Gwent and they recognise that they’re unlikely to meet the standard because of the physical place in which they’re currently located. And there’s some perhaps not very interesting in terms of a political discussion, but the technical way in which you need to design an area, the space that you need—all those things are really important aspects of actually delivering the outcomes that all of us here want to see. So, it will require capital investment, which will take some time. We should know the condition within each of our units, so there is a national workshop planned to consider that further and the unit reports are due to be received by health boards by the end of the year. We’ve also scoped out—no pun intended—the training programme, secured key elements of its delivery, and I’m hopeful that the first clinical endoscopist trainees will begin their training before the end of this calendar year. And these roles will be key to sustainable services given the challenging recruitment pipeline for doctors, who have until now been the main providers of investigations and interventions.

I can see that time is against us, Chair but I have provided a detailed response to the committee and I will, of course, keep Members and the committee itself updated on the actions that we are taken and progress that is made, and I have no doubt the committee themselves will return in the future to this report and the action the Government has undertaken to take today.

Thank you. I call on Dai Lloyd to reply to the debate.

Thank you very much, Deputy Presiding Officer. I’ve only got a brief amount of time left. Could I congratulate and thank everyone for taking part in this very important debate? Angela Burns, first, setting out the challenge—we need actions and solutions now. And, of course, to say the obvious thing: we need more specialist staff and more endoscopy units now to tackle this challenge.

I’m very grateful to Hefin David for setting out his recent experience, and also for saying that there are other diseases that we should be thinking about, not just bowel cancer, but also Crohn's and ulcerative colitis and so forth, and the importance of preparing bowels for colonoscopies in the first place, because we forget about preparing the most basic things.

I also thank Caroline Jones for emphasising the pressure on services and the importance of early diagnosis. Also, I thank the Minister for his positive response to the recommendation by the committee. We’re looking forward to seeing the action plan seeing the light of day. The challenge is significant, and the challenge requires a robust response now. Thank you very much.

Thank you. The proposal is to note the committee’s report. Does any Member object? No. Therefore the motion is agreed in accordance with Standing Order 12.36.

Motion agreed in accordance with Standing Order 12.36.