nature gastrointestinal unitedkingdom - bmj

Gut 1993; 34:1728-1739

SPECIAL REPORT

Nature and standards of gastrointestinal and liverservices in the United Kingdom

M J G Farthing, R Williams, C H J Swan, A Burroughs, R C Heading, J A Dodge, R I Russell,CW Venables, R Dick, R Burnham, R Leicester, G Neale, E T Swarbrick, P D Fairclough,R Jones, N P Melia

1. Purpose of the working party1.1 To describe the scope of major digestiveand liver disorders and identify changes inpatterns of disease.1.2 To identify diagnostic and therapeuticservices required to manage these disorders inthe United Kingdom.1.3 To describe the facilities and staffingrequired to provide these services.1.4 To examine the training requirements formedical, nursing, and other support staff.1.5 To define the part that audit and researchshould play in the provision and maintenanceof high quality gastrointestinal and liverservices.(Gut 1993; 34: 1728-1739)

British Society ofGastroenterology,Gastroenterologyservices working party ofthe clinical servicescommittee, St Andrew'sPlace, LondonM J G FarthingR WilliamsC H J SwanA BurroughsR C HeadingJ A DodgeR I RussellC W VenablesR DickR BurnhamR LeicesterG NealeE T SwarbrickP D FaircloughR JonesN P MeliaCorrespondence to:ProfessorM J G Farthing,Department ofGastroenterology, StBartholomew's Hospital, WestSmithfield, London EClA7BE.

Accepted for publication6 August 1993

2. IntroductionSince the publication of the document Provisionofa GastroenterologicalService in a District GeneralHospital, a monograph prepared by a workingparty of the Gastroenterological Liaison Com-mittee with the Department of Health and SocialSecurity in 1979,' diagnostic and therapeuticgastroenterological and liver services havedeveloped at a great pace. New and more effec-tive methods have been introduced in thediagnosis and treatment ofcommon disorders ofthe gastrointestinal tract. Endoscopy in particu-lar has become an increasingly important part ofthe gastroenterologist's workload. Endoscopictechniques are now used in the diagnosis andcontrol of upper gastrointestinal bleeding, in thenon-surgical treatment of benign and malignantstrictures of the oesophagus, in the removal ofgall stones from the biliary tract, in the manage-ment of extrahepatic cholestatic jaundice, and inthe diagnosis of colonic disorders includinginflammatory bowel disease, colonic bleeding,and in screening for colorectal cancer. As a

consequence, requests for diagnostic gastro-intestinal radiological examinations havedecreased and some major gastrointestinal andbiliary tract surgical procedures can be avoided.Expertise in interventional radiology is, how-ever, also required to support these therapeuticadvances. Hepatological areas in which specificclinical facilities and expertise is required are theadministration of anti-viral treatment for chronicviral hepatitis, management of portal hyper-tension, intensive therapy for fulminant liverfailure and liver transplantation - a majordevelopment in the care of patients with other-

wise untreatable, end stage liver disease. Thediscovery of Helicobacter pylon has increased thecomplexity of the treatment options for pepticulcer disease and gastritis, the management ofwhich may require special expertise.

Gastroenterologists (both medical and sur-gical) have taken an increasingly active role inthe provision of hospital and community basednutrition services including the organisation ofhospital nutrition teams, planning enteral andintravenous nutrition strategies for individualpatients, placement of central venous cannulas,insertion of feeding gastrostomies, and moni-toring treatment. As a result the total workloadof the gastroenterologist has escalated substan-tially during the past decade, which has onlypartly been met by an increase in the number ofconsultant physicians with an interest in gastro-enterology, which has risen from 245 in 1980 to340 at the end of 1991 (Appendix I). Although onaverage there is now one gastroenterologist for1:150 000 population there are regional dif-ferences throughout the UK. Seventeen healthdistricts still do not have a gastroenterologist, 37have only one gastroenterologist serving popula-tions of more than 250 000, and 34 healthdistricts have one gastroenterologist servingpopulations between 200-250 000 (AppendixII). These figures compare unfavourably withwestern Europe (1:60 000) and the USA(1:33 000). The disparity is further heightenedby the fact that most gastroenterologists inwestern Europe and USA no longer make amajor contribution to the provision of acutegeneral medical services. Eighty six per cent ofgastroenterologists in the UK continue to take ashare of the acute general medical admissions(Royal College of Physicians survey).The purpose of this report is to detail the

requirements ofgastrointestinal and liver servicesat a district and a regional level, to definestandards of care in gastroenterology and relatedspecialities, to anticipate medical, nursing andancillary manpower requirements for the future,and the needs for training and research ingastroenterology.

3. Digestive and liver diseases in the UnitedKingdomDisorders of the digestive tract and livercontinue to be an important cause of morbidityand mortality in the population, and in con-sequence represent a major caseload for general

1728

on March 16, 2022 by guest. P

rotected by copyright.http://gut.bm

j.com/

Gut: first published as 10.1136/gut.34.12.1728 on 1 D

ecember 1993. D

ownloaded from

http://gut.bmj.com/

Nature and standards ofgastrointestinal and liver services in the UnitedKingdom

practitioners and hospital doctors. In broadterms, 10% of patients seen in general practicehave digestive complaints and about 10% ofhospital admission are a result of diseases of thegastrointestinal tract. The common disorders,peptic ulcer and related disorders affect 1 in 15 ofthe population at any one time. Colonic, gastric,oesophageal and pancreatic cancer continue tobe important causes of death in the UnitedKingdom (Appendix III). Gastric canceraccounts for 8-10 000 deaths/annum, which isabout 10% of all deaths from cancer in the UK.Colorectal cancer kills 17 000 each year, beingresponsible for the deaths of seven times morewomen than those dying as a result of cervicalcancer. Gastrointestinal cancer accounts forabout 30% of all cancer deaths in England andWales. Inflammatory bowel diseases, ulcerativecolitis, and Crohn's disease affect at least 100 000people in the UK and the latter is increasing inincidence. Upper gastrointestinal haemorrhageis a major cause of hospital admission with amortality of 5-15%. Functional bowel disorderssuch as the irritable bowel syndrome probablyoccur in 20% or more of the UK population andconstitutes 30-40% of the outpatient gastro-enterology workload.

It is estimated that there are at least 750 000alcohol abusers in the UK, a substantial propor-tion of whom will go on to develop chronic liverdisease, acute and chronic pancreatitis, andpancreatic insufficiency. About 50% of liverbiopsies in alcohol abusers with abnormal liverbiochemical tests show established cirrhosis and25% alcoholic hepatitis. Death rates for cirrhosisin England and Wales have increased by morethan 50% in the last 30 years and death ratesattributable to alcohol have increased eightfold.Gastroenterologists often participate in the careof other patients with alcohol related problems.The demands on the service can be considerableas alcohol is implicated in up to 20% of acutesurgical and orthopaedic hospital admissions.The prevalence of other liver disorders such asprimary biliary cirrhosis, primary sclerosingcholangitis, and haemochromatosis have pre-viously been underestimated, and the first is nowthe most common indication for liver transplan-tation in the UK. A proportion of alcoholicpatients with cirrhosis are suitable candidates forliver transplantation and this will increase theneed for these services. Gall stone diseasecontinues to be an important problem in theUnited Kingdom with more than 20% ofwomenand 11-5% ofmen over the age of60 years havinghad gall stones or have had cholecystectomy.The incidence ofmany conditions such as chronicinflammatory bowel disease, gastro-oesophagealreflux disease especially in the elderly, alcoholrelated gastrointestinal disorders, cancer of theoesophagus, colon and pancreas, and adversedrug effects on the gastrointestinal tract and liverare almost certainly on the increase. For example,20-30% of acute gastrointestinal haemorrhagesare related to the ingestion of non-steroidal anti-inflammatory drugs.

4. The gastroenterologist's workloadMany gastrointestinal and liver diseases can now

be managed on an outpatient basis and thisconstitutes a substantial proportion ofthe gastro-enterologist's workload. Most of the gastro-enterologist's work is in the outpatient clinic andin day case endoscopy. The medical gastro-enterologist also continues to fulfil an active rolein the provision of acute general medical servicesincluding both inpatients and outpatients.District general hospital physicians admit/discharge 680-700 acute admissions each year.2Two regional surveys of district hospitalphysicians with a special interest in gastro-enterology, however, reported 900 and 750-1130admissions annually2 and a recent survey of 17regions in the UK carried out by the BritishSociety of Gastroenterology confirmed theseearlier findings when 135 gastroenterologists had133 920 deaths or discharges, averaging 992inpatient episodes/year, while the average forother physicians was 679.3 When day caseadmissions are included annual discharges forgastroenterologists increased to 1553 comparedwith 871 for other physicians. These additional682 cases represent the workload of gastro-intestinal endoscopy. Thus, while the physician/gastroenterologist continues to contributeequally to acute general medical services, work-load has risen substantially because of theroutine endoscopic commitments. In addition,out ofhours endoscopy has also increased becauseof the endoscopist's increasing role in thediagnosis and treatment of gastrointestinalbleeding and jaundice.

5. Gastrointestinal and liver services

5.1 INPATIENTGastrointestinal disorders account for 20-30% ofthe total number of inpatients cared for bygastroenterologists.2 As outpatient managementis now highly developed in gastroenterology,gastrointestinal inpatients often require dis-proportionally more medical and nursing timethan other patients because of the severity oftheir illness. Typical reasons for inpatient careinclude serious complications of inflammatorybowel disease including nutritional insufficiency,acute gastrointestinal bleeding, severe pan-creatitis, obstructive jaundice, complicatedgastrointestinal surgical problems, patients withfulminant hepatic failure, those having livertransplantation, and patients with majorcomplications of chronic liver disease such asascites and variceal bleeding. Many of thesepatients require integrated managementstrategies including physicians, surgeons, radio-therapists, and interventional radiologists.Medical and nursing care is delivered mostefficiently in a multidisciplinary inpatientfacility.4 Access to intensive therapy unit bedsis required for patients with hepatic failure andliver transplantation and complex gastro-intestinal surgery; high dependency beds arerequired for some patients with the complicationsof liver disease and severe pancreatic disease.

5.2 OUTPATIENTA gastroenterologist spends 2-4 sessions each

1729



j.com/


ecember 1993. D

ownloaded from

http://gut.bmj.com/

Farthing, Williams, Swan, Burroughs, Heading, Dodge, et al

week in the outpatient department seeing 1000-1500 new patients each year.23 Most of thesepatients (70-100%) will have gastrointestinal orhepatic disorders. About 30-40% of new out-patients will have functional bowel disordersincluding the irritable bowel syndrome and non-ulcer dyspepsia. Consultations with thesepatients tend to be longer than those with organicdisease as environmental stresses and psycho-logical factors need to be explored. Patients withchronic inflammatory bowel disorders and thosewith chronic liver disease because of thespecialised nature of these disorders, tend to usethe hospital outpatient department rather thantheir general practitioner as the main route forseeking medical advice about their condition.Physicians and surgeons in gastroenterology andhepatology commonly run joint clinics tofacilitate the integrated management ofconditions such as chronic inflammatory boweldisease, biliary disease, upper gastrointestinalcancer, and liver transplantation. The multi-disciplinary approach to outpatient care willprobably increase in those disorders in whichcombined management is the rule.

5.3 THE INTERFACE WITH GENERAL PRACTICEInitial investigation of patients with digestivedisorders commonly takes place in generalpractice and although small numbers of generalpractitioners are developing flexible sigmoid-oscopy and even gastroscopy for their patientsthere is increasing pressure for open access tohospital investigative services, particularly uppergastrointestinal endoscopy and flexiblesigmoidoscopy and colonoscopy, and 'fast track'access for patients presenting in general practicewith symptoms requiring urgent assessment.Almost 200 general practitioners are employed ashospital practitioners or clinical assistants inendoscopy, making a contribution in mostdistrict general hospitals. The development ofmedical audit and of standards for the careof common conditions will increase the require-ment for the establishment of clinical guidelinesand protocols for the care of digestive disordersagreed between practitioners and specialists.

5.4 DAY CAREAbout 40% of the workload of a physician/gastroenterologist will be day cases includingalmost all diagnostic and most therapeuticprocedures.3 This comparatively high figure isthe result of changing practices in endoscopywhere patients are no longer admitted overnightfor preparation for colonoscopy or endoscopicretrograde cholangiopancreatography (ERCP).With the continued development of endoscopictechniques it is anticipated that this proportionof the workload will continue to increase.Unquestionably, the day care approach ingastroenterology is economically - sound andproduces minimal disruption to the life of thepatient. It places increased demands, however,on administrative services to operate such asystem. Adequate reception, preparation, andrecovery facilities are essential to ensure that thisexpanding area of health care remains safe and

acceptable to the patient. Most other gastro-intestinal investigations such as liver, pancreaticand intestinal biopsies, gastrointestinal mano-metry, oesophageal pH monitoring, anorectalphysiological studies, non-invasive testing forbacterial overgrowth, pancreatic function tests,etc can be performed on a day case basis.Venesection for iron overload, iron infusion foriron deficiency, etc are usually performed as aday case, unless complications arise.

5.5 DIAGNOSTIC SERVICESAlthough the gastroenterologist is inevitablydependent on good radiological and laboratoryservices, many gastroenterology units haveestablished their own comprehensive array ofdiagnostic tests and procedures, which makesthem relatively autonomous. Endoscopy hasbeen the mainstay of diagnosis in patientswith gastrointestinal disorders but most depart-ments have set up in house or have easy access toa range of non-endoscopic investigations, whichare vital for the management of patients withgastrointestinal disorders (5.5.2). Most suchtests have been set up by individual consultantsand their junior staff on an ad hoc basis, oftenserviced by research fellows and research nursesbut not funded by the NHS. The situation iscurrently unsatisfactory but should improvewith an increase in the numbers of clinicalmeasurement technicians in gastroenterology,and with the establishment of appropriatebudgets to fund non-endoscopic diagnosticservices in gastroenterology.

5.5.1 EndoscopyA detailed account of Provision ofgastrointestinalendoscopy and related services for a district generalhospital was published in 19905 and prepared by aworking party set up by the clinical servicescommittee of the British Society of Gastro-enterology. This report sets out the applicationofendoscopy in clinical gastroenterology, definesstandards-for staff, patient care, and equipment,and makes detailed recommendations on theplanning, staffing, and equipment necessary fora purpose built endoscopy unit, which should beavailable in every district general hospital. Thedevelopment of flexible endoscopes has nowmade it possible to examine the entire gastro-intestinal tract, including the biliary andpancreatic ducts (Appendix IV). Endoscopicexamination of the upper gastrointestinal tractand the colon has tended to replace barium mealand barium enema examinations. In addition tovisualising the oesophagus, stomach, andintestine directly, it is possible to take biopsyspecimens for histological and microbiologicalexamination to increase diagnostic precision.Therapeutic endoscopy continues to develop.Dilatation of strictures, removal of colonicpolyps, and extraction of gall stones from the bileducts have now replaced the equivalent surgicalprocedures. These procedures are minimallyinvasive and highly cost effective. First linetreatment for variceal and non-variceal bleedingfrom the upper gastrointestinal tract is nowendoscopy based.

1730



j.com/


ecember 1993. D

ownloaded from

http://gut.bmj.com/

Nature and standards ofgastrointestinaland liver services in the UnitedKingdom

The number of endoscopic examinationsperformed each year continues to rise.Epidemiological data and audit of the work ofestablished endoscopy units shows that theannual requirements/head of population forupper gastrointestinal endoscopy is 1:100, forflexible sigmoidoscopy and colonoscopy each is1:500, and for ERCP 1:1000. For a districtgeneral hospital serving a population of 250 000this is approximately 3500 procedures each year.An endoscopy service should be consultant led.At least 10 clinical sessions including most of thesimple upper gastrointestinal diagnosticprocedures each week are required, six or moreof which should be consultant sessions. Theremaining 2-4 sessions, including most of thesimple gastrointestinal diagnostic procedurescan be covered by clinical assistants or staffspecialists.There is an increasing requirement for general

practitioners to have open access to endoscopicprocedures (gastroscopy, rigid, and flexiblesigmoidoscopy) and a desirability for 'same day'endoscopy when patients are seen by hospitalgastroenterologists in the outpatient depart-ment. An endoscopy service requires a purposebuilt suite of rooms, trained specialised nursespossibly including an endoscopy departmentassistant (analogous to an operating departmentassistant), and appropriate secretarial and clericalsupport for appointments, record keeping,reports and audit, all of which should becomputer based (sections 8.3, 9.3, 9.4, and 9.6).An endoscopy unit must be supported by anadequate day care facility, appropriate porteringservices, and thus achieve the same status as asurgical operating suite.

Safety in endoscopy has received considerableattention recently such that it is now vital thatunits should be provided with adequatemonitoring equipment, supplementary oxygen,and resuscitation equipment and adequatelyventilated, cleaning, and disinfection facilitiesfor endoscopes.Appendix V summarises the availability in the

UK of some of the more commonly used diag-nostic and therapeutic endoscopic procedures. Adetailed account of the results of this survey willbe published as a separate report.

5.5.2 Non-endoscopic gastrointestinalinvestigationsIn addition to endoscopy, the gastroenterologistrequires access to a variety ofother investigationsthat have become an established part of theirclinical practice (Appendix VI). District generalhospitals will not necessarily have all of thesetests established in house, but they should beeasily available on a sub-regional basis establishedthrough a network ofdistrict general hospitals orthe local teaching hospital. With the advent ofgastrointestinal endoscopy and biopsy, the timehonoured functional tests of absorption (faecalfat excretion, xylose absorption test, Schillingtest, etc) have become less widely used forscreening purposes, although still have theirspecific indications. Functional assessment ofoesophageal motility and 24 hour ambulatory pHmonitoring contribute to the diagnosis ofoesophageal disease and the choice of treatment.

Anorectal manometry and electophysiologicalevaluation are increasingly used for the assess-ment of constipated and incontinent patients,although generally only available in specialisedunits. Glucose and lactulose hydrogen breathtests are widely available for assessment ofbacterial overgrowth and small intestinal transittime respectively, and most units require accessto a test of pancreatic function (pancreolauryl,Lundh test, or PABA test). There has been anincreasing requirement to have access to non-invasive approaches to the diagnosis of H pyloriinfection. "4C or '3C urea breath tests have beenestablished in some departments while othershave used H pylori serology. As more effectiveeradication procedures are developed, non-invasive tests forH pylori will assume increasingimportance. Access to specific antibody tests forscreening for coeliac disease (anti-gliadin anti-reticulin and anti-endomysial antibodies) is alsodesirable.Appendix VII summarises the availability in

the UK ofsome ofthe more commonly used non-endoscopic tests in gastrointestinal disorders. Adetailed account of the results of this survey willbe published as a separate report.

Those involved in hepatology will requirefacilities for full virological study ofpatients withhepatitis (hepatitis viruses A, B, C, etc) includingHBV-DNA and HCV-RNA, tumour markers,autoantibody profiles, liver, iron and copperquantifications, and in those centres carrying outliver transplantation, the assays for measuringplasma concentrations of immunosuppressivedrugs such as cyclosporin A. In addition radio-logical services specific to liver disease areessential for the investigation and treatment ofpatients. These are specialist services, so thattransfer of patients will become necessary withina reasonable distance. The investigations includesplanchnic arteriography (selective mesenteric,coeliac, and hepatic arteriography) for diagnosisand chemoembolisation of hepatic tumours andpresurgical assessment of the splanchnic circula-tion. Hepatic venography and hepatic venouspressure measurements are required for diagnosisand monitoring ofportal hypertension. A furtherradiological procedure is the transiugular intra-hepatic portal systemic stent shunt, whichalready has a therapeutic role in some patientswith bleeding varices.

Gastroenterologists are highly dependent ongood quality gastrointestinal radiologicalservices (including interventional techniques),histopathology, and microbiology and it isdesirable that close links are developed withthese respective departments to ensure thedevelopment of effective services withoutduplication of effort. Shared nurses with abilityin both endoscopic and percutaneous proceduresare required and there should be full nursingcover for each department at all times. Manygastroenterology units have regular interdepart-mental meetings with radiologists and histo-pathologists to review the results of diagnosticprocedures and to facilitate continuing educationand audit. The full integration ofthese services isessential for the provision of high quality care ingastroenterology and hepatology. In additionthere is a need for the active support of specially

1731



j.com/


ecember 1993. D

ownloaded from

http://gut.bmj.com/


trained nursing staff and intensive caresupport.

5.6 THERAPEUTIC SERVICES

5.6.1 EndoscopyAppendix V details the range of therapeuticendoscopic procedures. Many of theseprocedures are performed on a day case basiswithin the endoscopy unit while others such astherapeutic ERCP, dilatation of malignant oeso-phageal strictures, and placement ofoesophagealendoprostheses require x ray screening and directcollaboration with the department of radiology.Rapidly developing areas of therapeutic endo-scopy, in addition to gall stone removal andstenting of strictures in the biliary tract, includetumour bulk reducing procedures with laser,diathermy or ethanol injection, photodynamictherapy, and brachytherapy (endoradiotherapy).A few specialised centres have lithotripsy for gallbladder stones but this is probably not widelyapplicable and thus will be restricted to a fewspecialised regional centres.

5.6.2 Clinical nutritionIt is now increasingly recognised that chronicdiseases, particularly those ofthe gastrointestinaltract, are almost inextricably linked with somedegree of nutritional insufficiency. PublicationofA positive approach to nutrition as treatment bythe King's Fund Centre6 has heightened aware-ness of the importance of the added risk thatundernutrition brings to patients, the ways inwhich undernutrition can be detected, and theimportance of providing appropriate nutritionalsupport both in the hospital and at home. Manygastroenterologists (physicians and surgeons)directly participate in nutritional assessment andnutritional support and many lead hospitalclinical nutrition teams and coordinate a multi-disciplinary team consisting ofclinicians, nurses,dietitians, and pharmacists. Close liaison needsto be established with departments of chemicalpathology, microbiology, and dietetics. Inaddition, the clinician's specific responsibilitiesinclude nutritional assessment and identificationof the most appropriate approach to nutritionalsupport, placement of gastrostomy and intra-venous catheters, prescription of parenteralnutrition solutions, planning enteral and othernutritional regimens, overall responsibility forthe nutritional aspects ofcare ofreferred patients,and for monitoring the results of treatment. Theaverage workload ofa nutrition team in a 740 beddistrict general hospital has recently beenassessed at 3000 patient days for enteral tubefeeding, 240 patient days for intravenousnutritional support, and 1200 patient days forhome enteral tube feeding.7 Recent evidencesuggests that there are also important economicadvantages in creating a team based nutritionservice.

Approximately 150 patients in the UnitedKingdom currently receive intravenous nutritionat home. This is a highly specialised service and acomparatively small number of centres in theUnited Kingdom provide the medical andnursing support for these patients. Home in-

travenous nutrition will continue to be super-vised by a limited number of centres led bya gastrointestinal physician or surgeon witha nurse specialist in nutrition. Home enteralnutrition, however, is increasing and appro-priate organisational structures are beingestablished between hospital and the com-munity. All patients on artificial nutritionsupport require to be closely monitored bygastroenterologists, often in dedicated nutritionclinics in liaison with chemical pathologists,dietitians, and nutrition nurses. There is a needto streamline the funding procedures for enteralfeeding preparations and equipment in coopera-tion with the community services. Some pro-gress is already being made in this matter.Endoscopic guided percutaneous gastrostomyis a growing technique for providing enteralnutrition and requires expertise of both theendoscopist and radiologist.

5.6.3 Stoma careNurse specialists in stoma care are an essentialcomponent of gastrointestinal services in thehospital and community. Ideally stoma carenurses should work in close liaison with medicaland surgical gastroenterology clinics. Stomacare nurses should be made aware of the decisionmaking processes associated with surgery thatwill probably result in a stoma, to permit thepatient to be appropriately prepared.

5.6.4 Psychological services in gastroenterologyA substantial proportion of outpatient gastro-enterology involves functional disorders of thegastrointestinal tract some of which have anunderlying psychological component. Manygastroenterologists have developed close linkswith a psychiatrist or clinical psychologist toassist in the assessment and treatment of suchpatients. Such services will probably be limitedto centres where there is particular interest andexperience in these disorders.

6. Paediatric gastroenterologyPaediatric gastroenterology has developedrapidly during the past 15 years although thereare still NHS regions without recognised paedi-atric gastroenterologists. Among paediatricgastroenterologists there is concern that manychildren are still deprived of the opportunity ofinvestigation by appropriate modern methodsand that they may receive treatment that issuboptimal. With the development of theadvanced endoscopic techniques that are nowavailable for the investigation of gastrointestinaldiseases in the paediatric age group and of newapproaches to nutritional rehabilitation, it is vitalthat specialists in this area should be available tochildren with these disorders. The British Societyof Paediatric Gastroenterology and Nutrition hasrecently examined regional services for paediatricgastroenterology and nutrition and produced areport.8 Because children are fundamentallydifferent from adults, they should not be treatedlike 'mini-adults'. The report recommends thateach region should have at least one identifiedreferral centre for children with gastrointestinal,liver, and nutritional disorders. It recommends

1732



j.com/


ecember 1993. D

ownloaded from

http://gut.bmj.com/


that children with these disorders shouldbe managed in a dedicated children's unit withclose collaboration with other specialists suchas paediatric surgeons, radiologists, and childpsychiatrists. Each referral centre should havea dedicated paediatric endoscopy unit butfailing this there should be designatedpaediatric sessions in the general endoscopyunit. In addition, each regional centre shouldhave the full range of other gastrointestinalinvestigations including oesophageal pHmonitoring, hydrogen breath testing, tests ofpancreatic function, and other specialistbiochemical tests including mucosal disacchari-dase activities, and an experienced nutritionsupport team.

6.1 HEPATOLOGYCurrently there are two major centres in the UKresourced supraregionally. Regional paediatricexpertise in hepatology will be important toensure early and appropriate referral to supra-regional centres.

6.2 PAEDIATRIC GASTROINTESTINAL SURGERYClosely integrated medical and surgicalmanagement is essential for conditions such assevere gastro-oesophageal reflux, biliary atresia,inflammatory bowel disease, meconium ileus,and protracted diarrhoea after neonatal surgery.Endoscopy services and nutritional support againshould be the joint responsibility of paediatricgastroenterologists and paediatric surgeons. Allsurgery in children under the age of two yearsshould be performed in a regional paediatricsurgical centre and never in adult units at anyage. Appendix VIII lists conditions that couldbe referred to regional paediatric gastro-enterology centres.

7. Surgical gastroenterologyThe extent ofa gastrointestinal surgery service ata district general hospital will depend upon thesize of the hospital, the population it serves, andthe number of general surgeons on its staff. Alldistrict general hospitals must provide a fullgastrointestinal emergency service but the levelof the service provided will vary. No unit shouldbe expected to provide a complete service forevery gastrointestinal problem. Surgicalexpertise in the management of rare but import-ant gastrointestinal problems can only bedeveloped by concentrating such cases in desig-nated centres on a subregional, regional ornational basis. It is considered that a surgicalgastrointestinal service can be provided on athree level basis depending on the amount ofspecialised expertise that is required for anyindividual case.

LEVEL 1This level must be available at all district generalhospitals and provide a 24 hour emergencycover, irrespective of the size of the population itserves. It will require a minimum of two gastro-intestinal trained surgeons to be available with

two or three other surgeons to provide supportfor the emergency work. The latter may havemajor interests in other fields but must not be sospecialised that they cannot support the twogastrointestinal surgeons with gastrointestinalemergencies. Similarly, the gastrointestinalsurgeons will need to have a sufficiently widetraining to support the other speciality interestswhen an emergency situation arises. Such a unitmight be expected to have at least one and ideallytwo general physician/gastroenterologists on thestaff.Emergency surgery - these surgeons must be

able to deal with acute appendicitis, intestinalobstructions, perforations ofthe bowel and otherintra-abdominal organs, acute cholecystitis,hernias and their complications, diverticulitis,major upper gastrointestinal bleeding, resuscita-tion of acute pancreatitis, mesenteric infarction,volvulus, etc. To provide these services theywould require access to upper gastrointestinalendoscopy and colonoscopy and be fully trainedin emergency endoscopy.

Elective surgery - the type of 'elective surgery'performed in such a unit should be limited tothose conditions/procedures that are seencommonly enough to maintain their expertise.They should not be expected to undertakecomplicated, difficult surgical procedures thatrequire considerable experience, substantialanaesthetic/laboratory support, and expertnursing and junior medical staff support. Suchproblems are identified under level 2.

LEVEL 2This would be provided in a larger institution orgroup of hospitals with at least eight generalsurgeons on the staff, four of whom would havebeen trained in gastrointestinal surgery. Thisinstitution would be expected to provide somesurgical services on a regional or subregionalbasis, receiving referrals from other small (level1) district general hospitals surrounding theirown district. The four gastrointestinal surgeonswould work closely with at least two medicalgastroenterologists and be supported by a fullendoscopic service including diagnostic andtherapeutic ERCP, intensive care includingrenal failure management, interventionalradiology, and advanced biochemical and labora-tory services. They would provide a range ofspecialised services dependent upon theirexperience and expertise. All of the gastro-intestinal surgeons would take part in theemergency service in association with the othergeneral surgeons and provide backup support forthe other surgeons if a major gastrointestinalemergency was admitted. All would havesessional commitments to endoscopy but thiscould be focused to their area of interest such ascolonoscopy for the coloproctologists and uppergastrointestinal endoscopy and ERCP for thosesurgeons interested in upper gastrointestinaland hepatobiliary/pancreatic surgery. Thespecialised services provided in such a unitwould be expected to include oesophageal,oesophagogastric, revisional gastric, pancreatic,hepatic and biliary reconstructive, specialisedcolorectal and anal surgery.

1733



j.com/


ecember 1993. D

ownloaded from

http://gut.bmj.com/


Elective emergency - the specialised surgicalservices covered by such a unit (depending onlocal expertise) might include oesophageal andoesophagogastric surgery; complicated biliarysurgery (for example, strictures, tumours, dif-ficult bile duct stones); hepatic and oesophagealvariceal surgery; surgical management of acuteand chronic pancreatitis; major pancreaticsurgery for cancer and tumours; recurrentintestinal fistulas; recurrent unexplained gastro-intestinal bleeding; severe complicated inflam-matory bowel disease; trans anal surgery, andsurgery for incontinence plus major laparoscopicsurgery.

LEVEL 3This type of unit would provide a highlyspecialised gastrointestinal surgical service on aregional or national basis. Itwould not necessarilyprovide a full range of gastrointestinal surgicalservices but would concentrate upon narrowareas, for example oesophageal varices manage-ment, liver resections; hepatic, pancreatic orintestinal transplantation; home intravenousnutrition; short bowel syndrome management,etc.The gastrointestinal surgical service is logically

stratified into levels depending on the patients'problems. It is vital that all concerned should beaware that not all district general hospitals can orshould be expected to provide a full range ofgastrointestinal surgical procedures. Referral toother surgical centres will always be likely,particularly when highly specialised, difficultsurgical procedures are required to treat thecondition.

8. FacilitiesGastrointestinal medicine and surgery shouldideally be closely integrated in the care ofinpatients and outpatients, both ofwhich shouldbe geographically allied to a purpose built endo-scopy unit, clinical investigation unit for non-endoscopic gastrointestinal investigations, andthe outpatient department. Proximity of theoutpatient department to endoscopy will facili-tate 'same day' investigations and a joint medical/surgical gastrointestinal inpatient facility willoptimise the shared care arrangements that havebecome desirable and unavoidable in manydisorders of the gastrointestinal tract. Officeaccommodation for medical staff and secretariesshould be provided adjacent to investigation andinpatient facilities.

8.1 INPATIENT FACILITYThe size of the inpatient unit would depend onthe population served, the referral practice, andspecific expertise of the gastrointestinalphysicians and surgeons. Centres dealing withcomplicated inflammatory bowel disease, shortbowel syndrome, complex nutritional problems,organ transplantation, and complicated pan-creatic disease will require more beds for theprotracted hospital stay that is often associatedwith these problems. Centres dealing withcomplex abdominal surgery, organ transplanta-

tion, and hepatic failure will require accessto high dependency and intensive treatmentbeds.

8.2 OUTPATIENT CLINICOutpatient services form a substantial part of agastroenterologist's workload and it seemsprobable that there will be a trend towards theprovision of more, but smaller, clinics to permitcloser adherence to appointment times andreduce waiting periods in the clinics. New con-sultant appointments will be required to reducewaiting time in the community. Waiting time todiagnosis will often include a second wait foroutpatient endoscopy or radiology. Attemptsshould be made to minimise this. Close proximityof the outpatient clinic to endoscopy willpromote 'same day' investigation by flexiblesigmoidoscopy and gastroscopy, which shouldreduce the time to diagnosis. Provision of suchan outpatient service is a desirable goal formedical and surgical gastroenterology.

8.3 DIAGNOSTIC SERVICES

8.3.1 EndoscopyThe requirements of an endoscopy unit havebeen described in detail' and should be providedin every district general hospital. The unitshould have adequate reception, waiting, andinterview/consultation facilities for patients andtheir relatives. Offices, change, and rest areas areneeded for administrative, nursing, and medicalstaff. Facilities must include an area adjacent totoilets for oral or enema bowel preparation forcolonoscopy. The unit should be convenientlysituated and adjacent to day care facilities, unlessthese are fully provided within the endoscopyunit. Because many inpatients are examined,the unit should be within easy access of thewards.Two endoscopy rooms are required to provide

18 sessions of routine endoscopy. A thirdprocedure room is desirable for flexiblesigmoidoscopy and other non-endoscopic gastro-intestinal investigations. A central cleaning/disinfection area must be provided adjacent tothe endoscopy room and must be designed tocomply with current Control of SubstancesHazardous to Health (COSHH) regulations ofthe Health and Safety Executive.

Endoscopic examinations such as ERCP,oesophageal dilatation and intubation, andcertain small bowel intubation investigationsrequire x ray facilities and radiologist support. Inan average district general hospital theseprocedures may require up to two sessions ofradiology/week. If ERCP services are provided,two further sessions may be needed. If thedepartment of radiology cannot provide spacefor these sessions in a convenient site, thenprovision of a purpose built ERCP room withinthe endoscopy unit should be considered topermit these facilities to be available at shortnotice and used flexibly by physicians andsurgeons. Alternatively, the endoscopy unitmight be equipped with a high quality C-armimage intensifier or screening unit.

1734



j.com/


ecember 1993. D

ownloaded from

http://gut.bmj.com/


8.3.2 Gastrointestinal measurement laboratoryA variety of non-endoscopic investigativeprocedures are now routine in the diagnosis ofgastrointestinal disorders (Appendix VI). Ideallysuch an investigation unit would be locatedadjacent to the endoscopy unit to avoid duplica-tion of reception and administrative facilities.Every district general hospital would not berequired to provide a comprehensive investiga-tive service, local arrangements being madebetween adjacent districts.

8.3.3 RadiologyAlthough the number ofbarium meal and bariumenema examinations in many districts hasdeclined in recent years radiological examinationof the gastrointestinal tract is a vital componentof diagnostic services in gastroenterology andhepatology. Every district general hospitalrequires access to standard barium examinationsincluding barium follow through examinationand enteroclysis. Good quality ultrasound andcomputerised tomography is vital to the investi-gation of many gastrointestinal and hepaticdisorders and should be available in every districtgeneral hospital and radiologists here shouldhave expertise in performing biopsies underultrasound or computed tomography guidance.Not all district general hospitals will provideinterventional radiological investigation of thebiliary tract although where this is providedappropriate time in screening rooms will benecessary. Intestinal angiography will not berequired in every district general hospital butprovision for this should be available on asubregional basis. The development of inter-ventional techniques such as therapeuticembolisation and transjugular intrahepaticportosystemic stent shunting (TIPSS) will belimited to specialist units.

9. Staffing

9.1 MEDICAL

ConsultantThe total number ofconsultant physicians with aspecialist interest in gastroenterology hasprogressively increased during the past 10 yearswith an average rate of 3% (compound)/annum(Appendix I). It is now considered that thereshould be one gastroenterologist/100 000population but this target has only been achievedin one region in England and Wales (AppendixII). Many regions have only one/150 000 or moreand in some there is only one for over 200 000 ofpopulation. Thus, there is still a need for newappointments of consultant physicians with aspecial interest in gastroenterology. A typicalconsultant contract for physicians with aninterest in gastroenterology and hepatologywould contain a commitment to:

Patient care - ward rounds and outpatients(4 sessions); endoscopy or other specialinvestigations (3 sessions); administration (1session); audit and teaching (1 session); studyand research (1 session).More than 80% of general physician/

gastroenterologists have a substantial commit-

ment to the acute general medical service, onaverage 1:4.5 days. They provide an emergencyendoscopy service for gastrointestinal bleeding,which has become an even greater commitmentwith the advent of therapeutic techniques for itscontrol and often organise the local nutritionservice. Many district general gastroenterologistscannot develop their endoscopic skills as newtechniques develop because this is precluded bynon-gastrointestinal clinical commitments.Junior medical staff - (a) senior registrar to

provide replacement of consultants; (b)registrars; (c) senior house officers and houseofficers.

Pernanent non-consultant staffAssociate specialists, hospital practitioners orclinical assistants can make an important contri-bution to patient care. It is anticipated that suchappointments will increase in future years,particularly to reduce waiting times for routinediagnostic and therapeutic endoscopy and tofacilitate the wider development of rapid accessclinics with same day diagnosis. It is not antici-pated that enrolment of staff grades will reducethe need for a continued expansion of consultantposts in gastroenterology.

9.2 NURSINGThere is no formal training programme fornursing in gastroenterology. Some specialisedunits, however, have developed local trainingprogrammes to establish special nursingexpertise. This is highly desirable particularly inwell integrated medical/surgical departments ofgastroenterology.

9.3 NURSE SPECIALISTS

EndoscopyNurses employed in endoscopy units shouldreceive relevant specialised training and thenurse in charge of an endoscopy unit requirestraining to a higher level so as to ensure highstandards and efficiency in the use, maintenance,and disinfection of the complicated equipmentand accessories used. There is an EnglishNational Board short course in nursing forgastrointestinal endoscopy and related proce-dures. Nursing staff have an important part toplay in the management of the endoscopy unit,including budgetary control, arranging instru-ment maintenance contracts and repairs,ordering supplies, supervision of secretarialstaff, answering queries, overseeing correct dataentry, labelling and transmission of specimensand reports, and ensuring that appointments andrebookings are correctly made.A two roomed endoscopy unit cannot function

at peak periods without six trained nurses. Twonurses are needed in each endoscopy room.Another qualified nurse should be responsiblefor patient preparation and explanation of theprocedure and another should supervise recoveryunless this is supervised by a nurse in a neigh-bouring day care unit. Six staffmust be employedto provide five on site, permitting 20% sick,study or annual leave. Time must be allocated

1735



j.com/


ecember 1993. D

ownloaded from

http://gut.bmj.com/


to the sister in charge for administrationand management. A district general hospitalproviding 10 sessions of routine endoscopy,mainly using one room at a time, but using a

second room for emergencies or flexiblesigmoidoscopies needs a sister (G grade), a seniorstaff nurse (F grade), and four nurses (E-Dgrades) to ensure four nurses on duty most of thetime and five at times of greatest activity. Forlarger units, and those providing ERCP or a

bronchoscopy commitment, extra endoscopytrained nurses will be needed.

Non-endoscopic gastrointestinal investigations -

in many units nurses take an active role inthe running of a clinical measurement laboratoryperforming a variety ofinvestigations from breathtests to manometry. No formal training pro-

gramme exists for these specialist nurses andtheir relation to the clinical measurementtechnicians needs to be established.

NutritionAn active gastroenterology unit in a districtgeneral hospital should have a nurse specialist innutrition to assist in the assessment of patients'nutritional state and to play an active part in theadministration of enteral and parenteralnutritional support in hospital. In addition, thenurse specialist should participate in dischargeplanning for patients returning to the communitywith continuing nutritional support and to liaisedirectly with community nurses for the provisionof continuing care.

Stoma care

A district general hospital requires two nurse

specialists in stoma care, to provide supportbefore and after surgical care both in hospital andthe community.

Gastroenterology specialist nurse practitionerThis new position, currently undergoingexpansion in gastroenterology, will providesimilar services to those of diabetic nurse

practitioners. Nurse practitioners in gastro-enterology will assist in outpatient clinics andwards, counselling patients about their diseaseand its management. They will liaise with bothhospital staff and healthcare workers in thecommunity. This development in gastro-enterology services is in line with the documentOn the Health of the Nation and thought to be an

advance in the care offered to patients.

9.4 ENDOSCOPY DEPARTMENT ASSISTANTSIn some endoscopy units operating departmentassistants (ODAs) have been trained to care forendoscopes and their sterilisation. A wider use ofan endoscopy department assistant is currentlybeing considered as this would relieve endoscopynurses of some of their non-patient orientatedduties. It is recommended that there should bean expansion of these posts within endoscopy

units.

9.5 CLINICAL MEASUREMENT TECHNICIANS

Many of the non-endoscopic investigations ingastroenterology are performed by clinical

scientists or medical technical officers (currentlyabout 50 in the UK), research nurses (about 25in the UK) or research fellows. Physiologicalmeasurement in gastroenterology is not recog-nised as a defined clinical need but it is recom-mended that posts of clinical measurementtechnicians should be established to perform thevariety of physiological and other tests that havebecome established as an important part ofclinical gastroenterology. An appropriate inservice training programme has been estab-lished, which has been endorsed by the Depart-ment of Health.

9.6 SECRETARIAL/ADMINISTRATIONAdequate provision must be made for secretarialand administrative support for a gastroenterologyservice. The secretarial and administrative loadin an endoscopy unit is often taken on by thesister in charge. With the increasing demands onthe nursing aspects ofendoscopy this is no longeracceptable. A standard district general hospitalendoscopy unit requires a full time secretary tocoordinate appointments, to maintain computerbased records to access data for audit, deal withtelephone enquiries, and perform receptionfunctions. Large, busy units may requireadditional clerical support.

10. Training in gastroenterologyThe training programme for senior registrars ingastroenterology invariably includes a generalinternal medicine component, which is providedfor both in the teaching hospital and districtgeneral hospital. Specialist training in gastro-enterology will include broad experience ininpatient and outpatient management of gastro-intestinal and liver disorders and a broad trainingin all diagnostic and therapeutic endoscopictechniques including ERCP. The joint planningadvisory committee currently accepts that aftergeneral professional training candidates wouldacquire specialist status after six years, of which2-3 years will be at registrar level, and 3-4 yearsat senior registrar level. A period of researchlasting 2-3 years leading to a postgraduatequalification is highly desirable and is essentialfor those aiming to work in teaching hospitalsand major district general hospitals.The Royal College of Physicians (London)

Committee for gastroenterology supported bythe clinical services committee of the BSG arepressing for a shorter revised schedule oftraining.In essence, after registration, this would providefour years in general medicine and four years inspecialist medicine. Selection for all specialitieswould take place during the final phase of thefirst four years and the training in specialistmedicine would include 12-18 months in someform of research (which might be bioscientific,clinical, epidemiological, or related to methodsproviding health care). There would be alterna-tive pathways for those seeking an academic orresearch career.A working group of specialist medical training

under the chairmanship of the Chief MedicalOfficer published a report in April 1993,Hospital doctors: trainingfor thefuture. This group

1736



j.com/


ecember 1993. D

ownloaded from

http://gut.bmj.com/


proposes that the duration of specialist trainingshould be reduced to seven years or less, thatthere be a unified training grade (career registrarand senior registrar combined) and that a certifi-cate of specialist training (CCST) should beawarded by the General Medical Council on theadvice from the appropriate college that a doctorhas completed a training programme.The specific implications of this report for

gastroenterology and the future training needs ofthe speciality will be considered by the newlyformed training committee of the BSG.During the period of clinical training, 20-25%

of a senior registrar's time should be available tocontinue research and postgraduate education.There should be some flexibility in the trainingprogramme depending on whether the candidatewishes to be a general physician with an interestin gastroenterology in a district general hospital,a consultant physician with an interest in gastro-enterology in a teaching hospital or an academicgastroenterologist.

11. AuditRegular and accurate audit is essential formaintaining and improving quality of clinicalcare. Experience with audit of clinical practicewithin single disciplines has shown widevariations in outcome. The multidisciplinarynature of gastroenterology makes accurate audita necessity of everyday clinical practice to assessand improve the outcome of jointly managedclinical problems.There are many areas where quality control in

the form of regular audit can be usefully applied.The management of acute upper gastrointestinalhaemorrhage where the application ofendoscopictherapeutic procedures have reduced operationrates and death need to be assessed withindistrict general hospitals where the gold standardresults from specialised centres should becompared with local practice and steps taken tomodify treatment protocols where necessary.Guidelines for good practice in audit of themanagement of upper gastrointestinal haemor-rhage have already been established by a jointworking part of the BSG, the research unit of theRoyal College of Physicians of London, and theaudit unit of the Royal College of Surgeons ofEngland.9 Management of inflammatory boweldisease, both from the point of view of sharedcare with primary care practitioners and the jointmanagement with surgeons and physicians toavoid the life threatening complications of thedisease should be audited to assess both outcomein terms of mortality and quality of life for thepatient.

Intraregional and regional to supraregionalaudit can identify guidelines for the best clinicalpractice for management of conditions requiringspecialised treatment.

Regular, multidisciplinary audit -meetings,including physicians, surgeons, pathologists,and radiologists should be an essential part of allunits providing gastroenterology services.Gastroenterology, nationally, already has a soundbasis for comparative audit in the multidisciplin-ary membership of the British Society ofGastroenterology and in the regional gastro-

intestinal societies where audit should be aregular agenda item.

12. ResearchTime and facilities for clinical and basic researchshould be available for consultants and trainees.Many gastroenterologists will wish to maintaintheir interests in clinical research, which can beperformed within the hospital setting. Some maywish to have laboratory facilities, within gastro-enterology or liver units or collaborate withscientists in basic science departments of theuniversity. These activities should be encouragedand fostered.The British Society of Gastroenterology

research advisory committee has developed 'Astrategy for research in gastroenterology' and hashighlighted two important areas in whichresearch in gastroenterology might be developedfurther. The committee identified a need to takea more active and direct part in developingresearch in the basic sciences relevant to gastro-enterology and also in health services researchand development.

Enhancing relations between basic science andclinical departments both in universities and otherinstitutions - it is recommended that heads ofdepartments should take a lead in developingjoint research projects for which joint fundingshould be sought. In addition, research trainingfellowships for well motivated young cliniciansintent on an academic career should be estab-lished and placed largely within basic sciencedepartments closely associated with clinicalgastroenterology units. For non-clinicalresearchers appointed to clinical units it is sug-gested that appointments should be held jointlywith bioscience departments and that thereshould be practical and tangible evidence of thejoint nature of these posts. A small number ofsenior clinical research fellowships should beawarded to leading researchers who are clearlycapable of developing strong independentresearch lines. Within these posts occupantsshould be able to pursue their research withoutthe pressure of heavy clinical and teachingcommitments.Enhancing health services research and develop-

ment - The British Society of Gastroenterologyhas set up a working party to examine ways inwhich specific research proposals can beformulated in areas of health service needs ingastroenterology. The working party will alsomake recommendations about the need fortraining programmes especially designed forresearchers in these fields. Future activities ofthe Society will include a teaching symposium onhealth services research to discuss the scope ofthis type of research and how it can beencouraged.

This working party report was accepted by the clinical servicescommittee of the British Society ofGastroenterology and approvedby the council of the British Society of Gastroenterology in June1993.

Members of the gastroenterology services working partyM J G Farthing (chairman), secretary, British Society of Gastro-enterology; R Williams, chairman, clinical services committee,BSG; C H J Swan, chairman, endoscopy section BSG;A Burroughs, chairman, liver section, BSG; R C Heading,chairman, oesophageal section, BSG; J A Dodge, chairman,

1737



j.com/


ecember 1993. D

ownloaded from

http://gut.bmj.com/

1738 Farthing, Williams, Swan, Burroughs, Heading, Dodge, etal

paediatric section, BSG; R I Russell, chairman, small bowel/nutrition section, BSG; CW Venables, chairman, surgical section,BSG; R Dick, chairman, radiology section, BSG; R Burnham,manpower, clinical services committee, BSG; R Leicester, audit,clinical services committee, BSG; G Neale, representative of theRoyal College of Physicians committee on gastroenterology. Co-opted members - E T Swarbrick, Wolverhampton; P DFairclough, London; R Jones, chairman; Primary Care Society forGastroenterology; N P Melia, Department of Health.

1 The British Society of Gastroenterology. Provision of gastro-enterological service in the district general hospital. London,1979.

2 Burnham WR, Lennard-Jones JE, Sladen GE. Staffing of acombined general medical service and gastroenterology unitin a district general hospital. Gut 1989; 30: 546-50.

3 SmithPM, Williams R. A comparison ofworkloads ofphysician-gastroenterologists and other consultant physicians. J R CollPhysicians Lond 1992; 26: 167-8.

Appendix I

NUMBERS AND DISTRIBUTION OF CONSULTANT PHYSICIANSWITH A SPECIAL INTEREST IN GASTROENTEROLOGY (DATAFOR 1980-1991)

Region 1980 1982 1986 1988 1990 Dec 1991

EastAnglia 7 8 9 11 13 13Mersey 10 12 12 12 12 16Northern 13 17 19 19 20 19North West 20 23 25 27 26 30Oxford 7 7 9 11 11 11South West 11 12 14 14 15 15Thames NE 27 33 34 35 40 45Thames NW 28 29 27 28 28 27Thames SE 22 22 23 26 30 29Thames SW 16 16 15 16 17 18Trent 17 18 22 26 24 26Wessex 13 13 13 15 16 16West Midlands 27 27 28 31 31 36Yorkshire 17 22 21 22 21 22Wales 10 11 14 14 15 17

Total 245 270 286 307 319 340

Appendix II

REGIONAL DISTRIBUTION OF PHYSICIAN/GASTROENTEROLOGISTS AND RELATION TOPOPULATION SIZE (DECEMBER 1991)

No ofsessionsNo of (specialist Populationl PopulationlWTE

Population consultants Gastroenterology) consultant (7 sessions)Region 103 103 10

Northern 3077 19 96 162 237Yorkshire 3605 22 107 165 240Trent 4646 26 145 178 221East Anglia 2014 13 65 154 223ThamesNW 3488 27 160 129 152Thames NE 3772 45 249 84 106Thames SE 3635 29 141 126 182Thames SW 2960 18 83 164 247Wessex 2905 16 79 182 265Oxford 2502 11 67 227 260South West 3206 15 65 214 357West Midlands 5198 36 203 144 179Mersey 2409 16 85 151 201North West 3991 30 144 133 194Wales 2836 17 85 estimated 167 235 estimatedEngland and Wales 50 244 340 1774 148 198

Appendix III

DEATHS FROM GASTROINTESTINAL AND LIVER DISORDERS

1986 1987 1988 1989 1990

GIandliverdisorders 60 928 61 115 61 784 63 014 58 598%totaldeaths 10-5 10-8 10-8 11 1 11 1GIcancer 40 353 40 698 40 986 41 135 38 379% total cancer deaths 29-1 29-0 28-8 28-7 28-6GI infection 173 160 162 185 182% total infection deaths 7-1 6-8 6-6 7-3 8-1GI cancer

oesophagus 4517 4762 4868 5008 4890stomach 9698 9496 9406 9062 8085colon 10996 11 351 11464 11 626 10 788anorectum 5803 5666 5751 5756 5368pancreas 6025 6045 5987 6116 5762

Peptic ulcer 4522 4297 4268 4399 4119Intestinal obstruction 2007 1899 1988 1989 1901Liver disease 2501 2672 2765 3016 2823

OPCS mortality statistics, England and Wales. GI=gastrointestinal.

4 Holman RAE, Davis M, Gough KR, Gartell P, Britton DC,Smith RB. Value of a centralised approach in the managementof haematemesis and melaena: experience in a district generalhospital. Gut 1990; 31: 504-8.

5 The British Society of Gastroenterology. Provision of gastro-intestinal endoscopy and related services for a district generalhospital. London: 1992.

6 King's Fund Centre. A positive approach to nutrition as treatment.London: 1992.

7 Burnham WR. The role of nutritional support teams. In:Payne-James J, Grimble G, Silk D, eds. Artificial nutritionsupport in clinical practice. London: Edward Arnold, 1994 (inpress).

8 Booth IW, Bell RAF, Boston V, Mowat AP, Miller V. Regionalservices for paediatric gastroenterology and nutrition. Reportofa sub-committee of the British Society ofPaediatric Gastro-enterology and Nutrition.

9 Joint Working Group. Guideliness for good practice in andaudit of the management of upper gastrointestinal haemor-rhage. JR Coll Physicians Lond 1992; 26: 281-9.



j.com/


ecember 1993. D

ownloaded from

http://gut.bmj.com/

1739Nature and standards ofgastrointestinal and liver services in the UnitedKingdom

Appendix IV

SPECTRUM OF DIAGNOSTIC AND THERAPEUTIC ENDOSCOPIC PROCEDURES

Diagnostic:

Therapeutic:Oesophagus

Stomach andduodenum

Colon

Pancreaticobiliary

Oesophagogastroduodenoscopy (routine and 24 hour emergency service)Colonoscopy/flexible sigmoidoscopyEndoscopic retrograde cholangiopancreatographyBiopsy, brush/needle cytologyEndoscopic ultrasonography

Dilatation of stricturesPlacement of endoprothesesTumour ablation (ethanol injection, laser)Variceal sclerotherapy and bandingBalloon myotomy (achalasia, diffuse oesophageal spasm)Haemostasis (ulcers, vascular malforsnations)PolypectomyBalloon dilatation of pylorusRemoval of foreign bodiesPercutaneous endoscopic gastrostomyPolypectomyHaemostasisBalloon dilatation of stricturesTumour reduction (laser, ethanol injection)SphincterotomyGall stone extractionLithotripsyCholedochoscopy/pancreatoscopyStents insertion (biliary and pancreatic)Tumour ablation (photodynamic treatment, brachytherapy, laser)Combined endoscopic/percutaneous radiological proceduresDrainage of pseudocysts

Appendix V

AVAILABILITY OF ENDOSCOPIC PROCEDURES IN THE UK*

No ofhospitals Open access to(%) general practitioners

Diagnostic upper GIendoscopy 201 (99) 121 (59)Variceal injection 176 (86) -

Haemostasis 158 (78) -

Balloon myotomy 139 (68) -

Diagnostic colonoscopy 198 (97) 18 (9)Polypectomy 198 (97) -

Haemostasis 124(61)Balloon dilatation 86 (42)

Flexible sigmoidoscopy 176 (98) 28 (13)Diagnostic ERCP 156 (79) -

Sphincterotomy 150 (74) -

Stone removal 139 (68) -

Stent placement 120 (59) -

*Data for 204 hospitals in England, Wales, Scotland andNorthern Ireland. GI=gastrointestinal; ERCP=endoscopicretrograde cholangiopancreatography.

Appendix VII

AVAILABILITY OF NON-ENDOSCOPIC GASTROINTESTINALINVESTIGATIONS IN THE UK*

No ofhospitals (%)

Oesophageal manometry 33 (16)Ambulatory oesophageal pH 86 (42)Gastric emptying

radionuclide 53 (26)ultrasound 27 (13)

Anorectal manometry 22 (11)Electromyography 7 (1-4)Hydrogen breath tests

glucose 58 (28)lactulose 70 (34)

Gastric secretion 81 (40)Pancreatic secretion 53 (26)Hpylori tests

Serology 65 (32)Antral biopsy, culture/history 186 (91)Urease test 142 (70)"C or 'IC urea breath test 42 (21)

* Data for 204 hospitals in England, Wales, Scotland andNorthern Ireland.

Appendix VI

NON-ENDOSCOPIC GASTROINTESTINAL INVESTIGATIONS

Gastrointestinal secretion Gastric secretionand absorption: Pancreatic secretion (Lundh, CCK/PZ)

Secretin test (gastrinoma)Intestinal perfusion testsVitamin B-12 absorption

Gastrointestinal motility: Gastric emptyingIntestinal transitOesophageal manometrySmall intestinal manometryAnorectal manometry and electrophysiology

Gastro-oesophageal reflux: 24 hour ambulatory oesophageal pH monitoringRadionuclide scanning

Visceral sensation: Rectal sensationBernstein test

Tissue biopsy: Intestine, liver, pancreas, etcBacterial overgrowth: Hydrogen breath tests

Duodenal intubationH pylori testing: 'IC or "C urea breath tests

Serology

Appendix VIII

CONDITIONS THAT COULD BE REFERRED TO REGIONALPAEDIATRIC CENTRES

1 Inflammatory bowel disease2 Protracted diarrhoea/vomiting3 Children requiring highly specialised diets4 Children requiring parenteral and enteral nutrition5 Children requiring specialised investigations including

endoscopy and jejunal biopsy6 Investigation of gastrointestinal bleeding7 Severe refractory constipation8 Rare conditions such as chronic intestinal pseudo-

obstruction and congenital defects in intestinaltransport

9 All forms of chronic liver disease10 Patients with fulminant liver failure or subacute liver

failure should be referred directly to a supraregionalcentre offering intensive care and liver transplantation



j.com/


ecember 1993. D

ownloaded from

http://gut.bmj.com/

nature gastrointestinal unitedkingdom - bmj

Documents