WAGE Heritage Review

By Dr Miles Allison August 2025

In late 2003 I was appointed as the first national clinical lead for endoscopy in Wales.  This was a one-day per week secondment to promote both the use of the Global Rating Scale, and improvements in waiting list management such as clinical validation, pooling and partial booking.  With Claire Lloyd, my managerial colleague, I visited every endoscopy unit in Wales and represented the country at national level via BSG Endoscopy and Clinical Services committees.  During these meetings I became aware of the thriving Scottish Society of Gastroenterology (SSG).  At that point, our only gastroenterology networking meetings were the North and South Wales Gut Clubs, and the annual Society of Physicians in Wales meeting at Portmeirion.  There was clearly a need for an association for gastroenterology in Wales to embrace surgical gastroenterologists, and joint working with those in the north and the south to further gastroenterology services and endoscopy training, and to become the National Specialty Advisory Group to the Welsh Medical Committee.

The Beginning of a Collaborative Vision

The first small meeting to brainstorm how the Association might work took place in October 2004.  I met with Drs Paul Duane, Barney Hawthorne, Roger Sheers, and Mr Jonathan Pye, all of us now retired. 

My suggestion of the acronym WAGE was to ensure medical gastroenterologists, surgical and specialist nurse endoscopists were all included in the initiative.  It was not lost on us that we might find ourselves “waging wars” with health boards and Welsh Government to promote endoscopy training and quality assurance, in part with a view to preparing the service for the introduction of bowel screening.  

The second inception meeting occurred in March 2005 with the five of us and Dr Terry Morris, Training Programme Lead for Gastroenterology, Mr Tim Havard, Secretary, Welsh Surgeons and Mr Mike Jamieson, Consultant Surgeon, Ysbyty Gwynedd Hospital.  Mr Tim Brown (JAG representative for Wales) was also consulted but was unable to attend in person. 

The idea of having an Executive Committee was born, and it was resolved to host annual meetings in mid-Wales in early October, with the Executive meeting before the annual meeting.

Challenges

At that time the medical gastroenterology community was quite small, with several single-handed consultants, typically undertaking both gastroenterology and general medicine across 17 sites in Wales.  Moreover, the contribution of consultants in Acute Medicine to general medicine was quite limited in those days.  In Wales, I found myself the only medic with ring-fenced sessions to devote to being founding secretary, but in reality most of the work was done from home in the evenings.

As well as what was once termed “manpower” shortages, Wales has geographic constraints, which underpinned the need for an all-day meeting which delegates could travel to and back from in a single day.  It soon became obvious that the Executive would need to stay overnight before the early morning meeting.

The inception committee resolved that WAGE should have scientific and educational components in addition to promoting gastroenterology and endoscopy services in both Wales-wide and national contexts.  We debated how the educational needs of doctors and non-medical healthcare professionals could both be met.  The concept of Associate Member status was agreed, with a plenary session in the mornings and parallel sessions for medical and nursing staff (Associates) in the afternoon.

We had given ourselves 6 months to plan the very first meeting under the WAGE badge and were pleased that the venue and conference expenses were funded by my seconding body, the National Leadership and Innovation Agency for Healthcare (NLIAH) which is now defunct.  In the future we would need to seek sponsorship from the commercial sector.

For WAGE to have governance credibility it needed a full constitution and a fee-paying voting membership.  I wrote the first draft of the constitution having had sight of that of both the SSG and the Welsh Thoracic Society.  The officer roles of the Executive Committee and their suggested terms of office were set out at the Inception Meeting.  In addition to the elected officers there was a need for trainee representation from medical and surgical gastroenterology, and an Associates representative.  Those acting as BSG and JAG representatives at national level would be co-opted onto the Executive for the duration of their national tenures. 

A representative from Welsh paediatric gastroenterology would complete the line up.  The Executive would meet every 6 months. There was also a need for administrative support for corresponding with potential sponsors and registration of delegates for meetings.  My then Research Secretary Mrs Alison Davey undertook this role for over a decade.

The 1st WAGE Meeting

And so the very first open WAGE meeting took place at the Metropole Hotel, Llandrindod Wells, in October 2005. 

The plenary topics were national work on endoscopy services and training, with contributions from senior Welsh Government and Public Health representatives on national strategic initiatives and how bowel screening was being rolled out in England. 

Dr Hilary Fielder, Screening Services Lead for Public Health Wales, was in the audience and observed that Wales spent more on gastric acid suppression than on bowel cancer! 

There was an inaugural open business meeting, followed by a free paper session for trainees with a prize at the end. 

Claire Lloyd facilitated a parallel session for nursing and managerial staff on good practice guidance in endoscopy waiting list management and quick wins.

Welsh Government

The first formal approach to Welsh Government was in July 2006.  A delegation from WAGE (myself, Nick Carr, Jonathan Pye and John Williams) met the then Health Minister, Dr Brian Gibbons and his officials, to make the case for the introduction of bowel screening in Wales, and the funding necessary to upskill potential screening colonoscopists and endoscopy training more widely. 

This proved highly successful, and £897k was allocated over 3 years for a training hub and spoke model based around WIMAT.  I was appointed as Professional Lead for introducing bowel screening, and Neil Hawkes and Bethan Davies as medical and nursing leads for the Welsh Endoscopy Training Network.  Formal hands-on training (and training the trainer courses) ensued.

Global Rating Scale

Implementing the Global Rating Scale proved challenging.  As clinical lead I had medical and nursing leads in the Southeast, Southwest and the North. 

I perceived a sense of GRS fatigue in the service, probably because the issue of long endoscopy waits seemed insoluble.  We used the October meetings to promote good practice, and had the UK experts from the JAG and the creators of the GRS as speakers in the plenary sessions. 

To this day only three acute hospitals in Wales are accredited, together with the Spire and Brecon War Memorial Hospitals.  Getting a relatively tiny satellite unit over the JAG accreditation line is not too difficult.

Website

Even though we registered our www.wage.org.uk domain early, it took too long for the website to be developed.  Eventually this was contracted out to Doodle IT in North Wales.

WAGE Presidents

Our Presidents in chronological order were John Williams, Jonathan Pye, Barney Hawthorne, Ashley Roberts, myself then Jared Torkington.  

We tried to ensure that a medical gastroenterologist alternated two-year terms with surgeons or radiologists. 

Hayley Heard was the first president with a nursing background, and she was succeeded by Dr John Green.

Achievements

As well as providing a forum for GI and endoscopic education and networking we helped to get bowel screening over the line.  Wales were regarded as the laggards in endoscopy service provision within the UK, yet we introduced full coverage of bowel screening for those aged 60-69 from October 2008. 

We had to compromise, and not mandate that units undertaking screening colonoscopy must be JAG-accredited.  So it was ironic that at a Four Nation endoscopy workshop in Belfast in April 2009, I was able to declare that Wales was, at that time, the only nation in the UK with full coverage for those age groups.  

As Professional Lead for bowel screening I did point out that there was an ethical concern introducing bowel screening into a service which struggled with long waiting times for its surveillance and symptomatic population, but of course the diagnostic and therapeutic benefit was far greater in the FOB positive population than in the other patients!

Being Professional Lead for bowel screening was the most challenging time of my career.  I had Thursdays ring-fenced for the work, but I had to sit on eight different founding committees and regularly visit units who had bid for hosting bowel screening.  These included all three North Wales Hospitals, two in west-Wales, Swansea, Royal Glamorgan, Llandough and Caerphilly Miners Hospitals. My managerial lead Hayley Heard and I were not infrequently emailing each other at midnight. 

In preparation for the launch I undertook media training for a day in June 2008.  The only problem was that my only BBC interview took place eight days before my media training.  Oliver Hides interviewed me with Glyn Jones, then MP for Montgomery, who himself had undergone surgery for colorectal cancer.  I got to know Glyn well with the launch and made the case for expanding and modernising endoscopy services on many occasions.

From 2011 WAGE launched a Wednesday awayday on a specialty topic.  These were to join key multidisciplinary stakeholders in specific subspecialties.  The first one was on provision of ERCP services and training.  This was partly prompted by the fall of trainees wishing to learn ERCP, with screening colonoscopy becoming the more fashionable kid on the block. 

As an ERCPist you know your procedure might lead to serious complications and even deaths, but you will salvage patients with severe cholangitis on intensive care.  The downside of that is that as an ERCPist you may get called in when not on call, even after you might have had a drink or two!  I was called in on New Years Day 2021, which angered my wife!   All bar one of the mainstream ERCPists were present, with all health boards represented, and there were guest speakers from Stoke and Liverpool.

Other awaydays during that decade included Barrett’s oesophagus, inflammatory bowel disease, viral hepatitis, bowel screening and early colorectal cancer, inherited predisposition to colonic neoplasia, earlier cancer diagnosis, hepatology, paediatric and transitional gastroenterology, and endoscopy supspecialisation and training.

From 2012 we hosted all-day Friday spring meetings, usually in South Wales.  These have now evolved into full two-day meetings.

There was a piece of serendipity regarding the Liver Plan.  Welsh Government called for a crisis meeting in 2013 to discuss endoscopy waiting times, and this was attended by Sir Ian Gilmore (BSG President with a special interest in liver disease and alcohol) and Dr Ruth Hussey (Public Health trained, then Chief Medical Officer for Wales).  

Unbeknown to us, they had worked very closely in Merseyside on alcohol services in the past and gave each other a very long embrace!  Ruth’s eyes glazed over when the endoscopy challenges were being discussed.  When the idea of a liver plan embracing alcohol came up, they both woke up she immediately agreed to fund this.  It got over the line as a Major Health Condition for funding just in the nick of time!

Ever since that moment, liver disease has had a major part to play in the activities of WAGE, with funding of several specialist fellowships for example.  It was ironic to dig up the following clairvoyance from my minutes of WAGE Exec from 2012:

“Dr Allison summarised the Welsh Government initiatives in this area, mainly a public health campaign and also the establishment of Area Planning Boards (APBs) which are funded via the Department of Local Government and Communities (as opposed to the Department of Health and Social Services).  The area planning boards will, from next April, be set up to commission alcohol and substance misuse services.  The APBs will be performance managed on crime reduction rather than mortality reduction or reduction in A&E admissions.  There are concerns from within secondary care services in Gwent that the local area planning board is large and unwieldy with little secondary care representation.  Others expressed concern about the potential difficulties in implementing the BSG, Royal College of Physicians and NICE recommendations on establishment of teams of specialist nurses and multidisciplinary teams for management of patients with alcohol related hospitalisation.  It has been noted that access to alcohol rehabilitation services is fast-tracked for those who commit crimes and are referred from the police and justice services, at the expense of those who would benefit on the basis of presenting with alcohol-related disease.  It was agreed that we need to link to the Welsh Psychiatric Society and to the A&E consultant body to discuss how to proceed, possibly by producing a paper for the Welsh Medical Committee.  Perhaps we can involve Ian Gilmore and BSG Strategy in helping with lobbying in this regard”.

The Liver Plan took off, with funding for alcohol nurses, Fibroscans and Hepatitis C elimination.  There was £5m over 5 years. WAGE has also funded several specialty endoscopy fellowships to Tokyo, for example.  The key players were Drs Andrew Yeoman and Jane Salmon, the latter from Public Health Wales, each with two sessions per week devoted to the Plan.  Dr Brendan Healy won BMJ Team of the Year award for work towards elimination of chronic hepatitis C in Wales.

Amusing and eventful moments

We appointed Dr Neil Hawkes and Sister Bethan Davies as medical and nursing leads for endoscopy training in Wales.  They became husband and wife and remain so today.  It is not the first time I played Cupid in my medical career – at the Royal Free in the 1980s I prescribed Indomethacin to an elderly woman with asthma and heart failure for an acute arthritis.  She ended up on CCU, and my gorgeous House Officer met the SHO on that unit and they married.  They ended up in his home country New Zealand!  I’d have gone after Lyndy if I wasn’t already in a relationship with Caroline!

Another facet was the meeting venue – the Metropole Hotel in Llandrindod Wells.   We used to compete for breakfasts with the Blue Rinse Brigade, who used to come in coaches to mid-Wales each autumn.  The Metropole did manage to host decent WAGE dinners from 2006, and some of the presidential speeches were amusing.  Our latter day President Sunil Dolwani developed antibodies to the Metropole, and to be fair the audiovisual technology was patchy.

My media training finally came in handy when I was interviewed by Tim Rogers on “Week in Week out” for BBC 1 Wales.  A then north-Wales MP Ann Clwyd had sounded off to the media over the “substandard” care of her late husband with cancer.  I was able to point to the creation of multidisciplinary teams working to cancer standards.

In my valedictory speech as WAGE President in 2016 I showed an old slide of Sunil Dolwani with one side of his hair grey and the other remaining dark.  I observed that we had worked him so hard with bowel screening and interventional colonoscopy that his hair is all the same colour now!

The most surreal moment came in March 2018.  Even though I had demitted office I was immediate past president and still on the Exec.  I was the Chair of the Organising Committee for a five-society meeting we termed DDW Wales 2018, working with BSG, Welsh Surgeons and Welsh chapters of AUGIS and ACP.  Creative Conferences led by Nikki Lee took charge of the organisation and liaison with Holland House Mercure, Cardiff.  A very glossy conference booklet was produced, with a sun-tanned photo of myself in the USA from the year before offering “a warm welcome to our capital city on St David’s day”.  As it turned out I could not have been more wrong!

We welcomed lots of big names from all over the place including Indiana and Milan, as well as all the BSG hierarchy.  The problem was the “Beast from the East” – a red weather warning centred around Cardiff.  The Mercure heating failed on the Thursday morning, and people had to wear their coats in the auditorium.  It was even colder in the pharmaceutical stand area.  The then BSG President, Martin Lombard, a caustic Irishman, asked me “Miles, what else could possibly go wrong?”.  I fell into the floor.  Only 75 delegates were there for the main day and 25 for the Friday – mostly those who stayed overnight or walked to the venue in Cardiff.  Many speakers could not arrive, but the guys from the US and Italy had extra talks on their USBs, and Sunil presented the CONSCOP data for the first time.  A nice cosy and cerebral Friday morning.

The social aspect of that meeting was amazing.  Those who attended the conference dinner sang like crazy – including five of my then eight GI surgical colleagues.  I had printed off sheets of Peter Cotton’ song “There is an endoscopist in Town” and my “Come to Wales” in the tune of Bread of Heaven.  There was a kind of siege mentality.

I tried to leave on the Friday lunchtime but reversed my car against the Mercure basement concrete and slithered in the ice, so I admitted defeat and went back to the Mercure.  Fourteen of us were stranded, mainly North Wales consultants and pharma reps.  A mini queue formed at the Mercure reception after lunch with us having to book a third night.  Behind me in the queue was Dr Rachel Newbould from Bangor.  I asked for a room and the receptionist said – right a double room for you.  I observed “that would be a different way to spend the afternoon”!

Hayley Heard, the nurse specialist I’d appointed to establish bowel screening back in 2007, became WAGE President in 2021, and modernised the constitution and governance of the Association.  The logo was re-invented with the bottom part of the “g” gut out against a red background.  On a subsequent Teams I complained that the “g” of our WAGE logo had been circumcised.  I’m pleased to see that if you go on the membership page of the website, the fully fledged “g” can be appreciated!

The Future

I believe the awaydays have been incorporated into the main meeting.  Separate awaydays were a fabulous forum for networking and progress towards national goals and gave us the opportunity to invite expert speakers from all over the UK who we might not normally access.

We tried to work towards centralising EUS services.  There is a concern that everything ends up centralised under Cardiff and Vale.  Maybe some services, such as bariatric surgery, should be delivered in Swansea, Newport and Wrexham.

Wales-wide endoscopy reporting will enable trainees to have their procedure data under one umbrella, and would facilitate audits and outcomes evaluation.  

It would be good to attract more representation from surgery, GI radiology and pathology.   WAGE was established to improve the experience for patients with gastrointestinal and liver disorders.  We could look at delivering more patient experience fora.

I believe one reason that luminal gastrointestinal and nutrition provision has been eroded is the new kid on the block:  POTS and the demand for post-pyloric feeding especially among older girls and younger women.  This was never an issue when I started as a consultant in 1991, and indeed I don’t recall it presenting till around 2015.  It is burning out luminal gastroenterologists who have to manage such patients and their families at the end of busy ward rounds, ironically meaning they miss their lunch!  

Some of these patients are highly manipulative, pulling out their feeding tubes that had been deployed under GA, then posting on Facebook pictures of their dislodged PEG/J tubes due to the incompetence of their endoscopists.

Quaternary centres such as Salford have MDTs with psychiatric input who can provide joined-up care for such patients.  For Wales, maybe having a national conversation about these disturbed patients would help those in the unfortunate position of having to care for them.